INSTRUCTIONS:
Inspection to Obtain Insignia: Complete Sections 1, 2, 3, 4, 5 and Contractor/Owner-Builder Declarations. Submit the application and the required fees to one of the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule the inspection date.
Alteration, Addition or Conversion: Complete Sections 1, 2, 3, 4, 5, and Contractor/Owner-Builder Declarations. Submit the completed application and required fees to the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule the inspection date.
Technical Services: Complete Sections 1, 2, 3, and 5. Submit the completed application and required fees to the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule an appointment for services.
Southern Area Office |
Northern Area Office |
3737 Main Street, Suite 400 |
9342 Tech Center Drive #550 |
Riverside, CA 92501 |
Sacramento, CA 95826 |
(951) 782-4420 |
(916) 255-2501 |
Alternate Approval: Complete Sections 1, 2, 3, 4, and 5. Submit the completed application and required fees to: Department of Housing and Community Development, Manufactured Housing Section, P.O. Box 31, Sacramento, CA 95812-0031. If you have any questions you may contact the Department at (916) 445-3338.
SECTION 1 - UNIT INFORMATION: Check one box to indicate the type of unit for which you are requesting services. If Commercial Coach, also indicate the Occupancy Group Code (i.e. B2, E2, A1, etc.) in the space provided. Enter the unit serial number(s). The serial number(s) can be located on the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or on the front cross member of the unit. Enter the year the unit was manufactured. Enter the manufacturer's name and/or trade name. This information can be obtained from the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or may be designated on the outside of the unit itself. Enter the decal or license number. This number is located on the license plate issued by DMV or the decal issued by the Department of Housing. Enter the California Insignia Number(s) or HUD Label Number(s) that were issued for this unit, if known.
SECTION 2 - OWNER/APPLICANT INFORMATION: Enter the owner's name(s) and address of the unit. If the address for the owner is different than the location of the unit, provide that information is the "Location Address" area. If the applicant is other than the owner, enter the name, address and telephone number of the applicant. The Department will contact or correspond with the party that is entered as the applicant. If the applicant is the same as the owner, the applicant information is not required to be completed.
SECTION 3 - CONTRACTOR, ARCHITECT OR ENGINEER INFORMATION: If the services are being performed by a contractor, enter the contractor's name and address. Also enter the contractor's license expiration date. If requested services involve an Architect or Engineer, enter the architect or engineer's name, address and license number.
SECTION 4 - DESCRIPTION OF WORK/ACTIVITY AND VALUATION: Provide a description of the work to be performed (i.e., installing a new roof, installing new windows, etc.) Enter the total cost of the work to be performed (total contact price).
SECTION 5 - SIGNATURE AND CERTIFICATION: The signature of the applicant is required along with the date the form is signed. If the
application is for a replacement insignia or HUD label, the signature must be of the owner of the unit.
CONTRACTOR/OWNER-BUILDER DECLARATIONS
Contractor: Contractors proposing construction are required by state law to provide the following information:
Item 1 - Licensed Contractor Declaration: Enter the contractor's license class, license number, license expiration date and the contractor's signature and date.
Item 3 - Workers' Compensation Declaration: Place a check mark next to the declaration regarding the workers' compensation coverage that applies to the contractor. If the second declaration is marked, the contractor must also provide the carrier's name and policy number. This item must be signed by the contractor and dated.
Item 4 - Construction Lending Agency: If there is a construction lending agency for the performance of the work for the service being requested, enter the name and address of the lending agency. If there is no lending agency involved, enter the word "none".
Item 5 - Certification: The certification must be signed and dated by the contractor or and agent on behalf of the contractor.
Owner-Builder: If the work or activity as described on the application, is being completed by the owner, the owner must complete the following items:
Item 2 - Owner-Builder Declaration: Place a check mark next to the declaration which is applicable. If the third declaration is marked, enter the section number from the Business and Profession Code which provides the exemption and the reason for the exemption. The owner must also sign and date this section.
Item 5 - Certification: The certification must be signed and dated by the owner.
DEPARTMENT USE ONLY
APPROVAL OF THIS APPLICATION IS CONDITIONED TO COMPLIANCE WITH REGULATIONS OF THE DEPARTMENT: Any approval issued by the
Department pursuant to this application is conditioned upon the applicant's compliance with the applicable provisions of the California Administrative Code, Title 25, Chapter 3, and the Business and Professions Code as it relates to contracting.
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