Fillable Application Form - FILLABLE (REVISED 6-25-19)

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Application Form - FILLABLE (REVISED 6-25-19)

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The Application Form - FILLABLE (REVISED 6-25-19) form is 2 pages long and contains:

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  • 16 check-boxes
  • 40 other fields

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Date: _________ Permit #_______________
#1 IDENTIFY YOUR BUILDING PROJECT
Property Location or Address: _________________________________________________________________
This permit is to be issued in the name of the Licensed Contractor or the Property Owner as the permit holder of
record who will be responsible and liable for the construction.
Property Owner Information: Name _____________________________________________________ Tel No___________________________
Parcel Number: _____________________________________________________________________________________________________
Mailing Address_____________________________________________________________________________________________________
Applicant’s Name _________________________________________________________Tel No ________________________________
Applicant’s Email ____________________________________________________
Project is: Residential Non-Residential Home Owners Association? Yes No
Type of work is: New Construction Addition/Alteration Other
Description of work to be performed:___________________________________________________________________________
__________________________________________________________________________________________________________________
Occupancy Use________________________ Occupancy Load ________________ Type of Construction ___________________________
Existing Bldg sf___________ New Area sf ____________Mezzanine sf______________ Other _____________________
Valuation of work to be performed: $__________________________
Licensed Design Professional (Architect or engineer in charge of the project) Information:
Name _______________________________________________ License No.___________________ Tel No. _________________________
#2 IDENTIFY WHO WILL PERFORM THE WORK (Complete either 2a or 2b)
2a – CALIFORNIA LICENSED CONTRACTOR’S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code, and my license is in full force and effect.
Contractor Name:________________________________________________ Class:_____________ License No._____________________
Address:_________________________________________________Contractor Signature:_______________________________________
2b – OWNER-BUILDER’S DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors’ State License Law for the reason(s) indicated below by the
checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the Contractors’ State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred
dollars ($500).):
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or (_) portions of the work,
and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors’ State License Law does
not apply to an owner of property who, through employees’ or personal effort, builds or improves the property, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner-Builder will have
the burden of proving that it was not built or improved for the purpose of sale.).
City of Chino - Building Division
13220 Central Avenue, Chino, CA 91710
909-334-3251
BUILDING PERMIT APPLICATION
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(_) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business
and Professions Code: The Contractors’ State License Law does not apply to an
owner of property who builds or improves thereon, and who
contracts for the projects with a licensed Contractor pursuant to the Contractors’ State License Law.).
(_) I am exempt from licensure under the Contractors’ State License Law for the following
reason:_______________________________By my signature below I acknowledge that, except for my personal residence in which I must
have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have
built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law,
Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site:
http://www.leginfo.ca.gov/calaw.html.
Property Owner or Authorized Agent signature________________________________________ Date ________________
#3 IDENTIFY WORKERS’ COMPENSTATION COVERAGE AND LENDING AGENCY
WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER
TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
WORKERS’ COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(_) I have and will maintain a certificate of consent to self-insure for workers’ compensation, issued by the
Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued. Policy No. ________________________________________________
(_) I have and will maintain workers’ compensation insurance, as required by Section 3700 of the Labor Code,
for the performance of the work for which this permit is issued. My workers’ compensation insurance carrier and
policy number are:
Carrier__________________________ Policy No_______________________ Expiration Date_____________
Name of Agent ____________________________________________ Tel No __________________________
(_) I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as to become subject to the workers’ compensation laws of California, and agree
that, if I should become subject to the workers’ compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
Signature________________________________________________________________ Date________________________________
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work
for which this permit is issued (Section 3097, Civil Code).
Lender’s Name and Address__________________________________________________________________
#4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify to each of the following:
I am (_) a California licensed contractor or (_) the property owner* or (_) authorized agent**.
I have read this construction permit application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to enter the above-identified property for inspection purposes.
*requires separate verification form
**requires notarized letter.
Signature ________________________________________________ Date _________________________
THIS APPLICATION AND SUBSEQUENT APPROVAL WILL EXPIRE BY LIMITATION WITHIN
180 DAYS FROM THE SUBMITTAL DATE OF THIS APPLICATION OR APPROVAL.
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Application Form - FILLABLE (REVISED 6-25-19)

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Completed 3 June 2021

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