Fill - Free fillable Application-for-Building-Permit PERMIT APPLICATION PDF form

PERMIT APPLICATION

Community Development Department

Development Services Center

39550 Liberty Street, Fremont, CA 94538

Phone (510) 494-4460 Fax (510) 494-4820

PLEASE COMPLETE THE FOLLOWING PROJECT INFORMATION – PLEASE PRINT

PROJECT ADDRESS: ________________________________________________________________________________________________________________________________________

PROJECT DESCRIPTION:_____________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________

OWNER NAME: ______________________________________________________ PHONE: ___________________________ E-MAIL:__________________________________________

OWNER ADDRESS: ______________________________________________________________________________________ FAX : ____________________________________________

APPLICANT NAME:___________________________________________________ PHONE: ___________________________ E-MAIL:__________________________________________

APPLICANT ADDRESS: ___________________________________________________________________________________ FAX:_____________________________________________

CONTRACTOR NAME: ________________________________________________ PHONE: ___________________________ E-MAIL:__________________________________________

CONTRACTOR ADDRESS:________________________________________________________________________________ FAX:_____________________________________________

ARCH./ENG. NAME: __________________________________________________ PHONE: ___________________________ E-MAIL:__________________________________________

ARCH./ENG. ADDRESS: __________________________________________________________________________________ FAX:_____________________________________________

LICENSE NO.:_______________________________________________________________________________________________________________________________________________

TOTAL PROJECT VALUATION: $ ____________________________________________________________________________________________________________________________

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.

WORKERS’ COMPENSATION DECLARATION

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.

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: ___________________________________________________________________

Agent: __________________________________________ Phone No. ______________________

___ I certify that, in the performance of the work for which this permit is issued, I shall not employ

any person in the manner so as to become subject to the worker’s 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 of Applicant Date

License Class

License No.

Expiration Date

Contractor

(Signature)

______________________________________________________

OWNER-BUILDER 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.)

___ 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:

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).

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

_________________________________________________________________________________

Signature of Property Owner or Authorized Agent Date

___________________________________________________________________________

Lender’s Name

__________________________________________________________________________

Lender’s Address

BY MY SIGNATURE BELOW, I CERTIFY TO EACH OF THE FOLLOWING:

I am the property owner or authorized to act on the property owner’s behalf.

I have read this 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.

______________________________________________________________________________

Print Name of Applicant Date

______________________________________________________________________________

Signature of Property Owner or Authorized Agent

OFFICE USE ONLY: Flood Area: Yes _____ No ______ Planning No.: __________________________________________

Fire Hazard Area: Yes _____ No _____

Inspection Area: ______________________ Building Permit No.: BLD 20_______________________________

BSD-100 Form Permit Application JH 07.2014 Page 1 of 2

click to sign

signature

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BLD_______________________________________________

FIXTURE WORKSHEET

Quantity

ELECTRICAL:

New dwelling 1-2 family ____________

New dwelling 3+ family ____________

Nonresidential Circuits (including motors, heaters,

generators, furnaces, welders, transformers, and

rectifiers) ____________

Residential system additional circuit:

Appliance Center ____________

Baseboard heater ____________

Built-in appliance ____________

Dishwasher ____________

Dryer ____________

Exhaust fan ____________

Furnace fan ____________

Garbage disposal ____________

Kitchen hood & fan ____________

Range ____________

Washer ____________

Water heater ____________

Other ____________

Fixtures, switches, and/or receptacles ____________

Fixtures, other-mercury vapor, high or

low pressure sodium ____________

Service Panel (amps per panel)

# Amps # Amps # Amps

____ ________ ____ _________ _____ _________

Temporary service (service pole) ____________

Temporary service-additional drops ____________

Other ____________

GREEN BUILDING

Commercial/Industrial, new or existing (per unit) ____________

Residential, New 1-2 family dwelling (per unit) ____________

Residential, New 3+ family dwelling (per unit) ____________

Residential, Addition PER 500 square feet ____________

MECHANICAL

New dwelling 1-2 family dwelling, initial system ____________

New dwelling 3+family dwelling (per unit) ____________

Air Handling with automatic shutoff ____________

Air Handling without automatic shutoff ____________

Boiler or Compressor ____________

Fire Damper ____________

Furnace – floor, including vent (# of systems) ____________

Gas piping system (# of outlets) ____________

Heater-floor mounted ____________

Heater-suspended ____________

Heater-wall ____________

Quantity

MECHANICAL (continued)

Heating/cooling appliance repair, alteration or addition ____________

Heating/cooling or ventilation system repair, alteration

or addition-no other fee listed ____________

Hood - Type I and Type II including duct ____________

Domestic type incinerator installation/relocation ____________

Incinerator nonresidential installation/relocation ____________

Process piping-non-hazardous (per system) ____________

Process piping-hazardous (per system) ____________

VAV control box ____________

Vent (appliance) - not included with appliance ____________

Ventilation system for hazardous material ____________

Ventilation system – not part of any HVAC system ____________

Other _______________________________ ____________

PLUMBING

Residential

New dwelling 1-2 family ____________

New dwelling 3+ family ____________

Fixtures per trap ____________

Gas piping system (per outlet) ____________

Drainage or vent piping repair or alteration ____________

Rain water system (per drain) ____________

Sewage disposal system – private ____________

Water heater ____________

Water piping and/or water treating equipment ____________

Other ________________________________________ ____________

Nonresidential

Fixtures per trap ____________

Lawn sprinkler system –backflow devices (per meter) ____________

Gas piping system (per outlet) ____________

Storm drain – 10” diameter or greater (per system) ____________

Storm drain – less than 10” diameter (per system) ____________

Interceptor-industrial waste pre-treatment ____________

Interceptor-nonresidential kitchen –grease ____________

Rain water system (per drain) ____________

Sewer – building or trailer park ____________

Vacuum breakers for equipment ____________

Water piping and/or water treating equipment ____________

Water heater and/or water heater vent ____________

Other __________________________________________ ____________

FIRE

Automatic Fire Extinguishing System

Alarms and/or detectors ____________

Sprinkler heads ____________

Underground fire line ____________

Valves/water flow supervision ____________

Fire Code

Assembly permit ____________

Compressed gas extinguishing system ____________

Dry chemical extinguishing system ____________

Halon (clean agent) extinguishing system ____________

High pile combustible storage ____________

Hood and duct suppression system ____________

Industrial oven ____________

LPG container ____________

Spray booth ____________

Tent, Canopy, Temp Membrane Structure ____________

Other ________________________________________ ____________

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