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CITY OF MILPITAS
Building & Safety Department
455 E. Calaveras Blvd.
Milpitas, CA 95035
408-586-3240
www.ci.milpitas .ca.gov
CONSTRUCTION
PERMIT
APPLICATION
DATE:
BUILDING PERMIT #B - _________--___________
PROJECT ADDRESS:
Suite/Unit #
PROPERTY OWNER:
Name/Company:
Address: City: State Zip
Phone ( ) Fax ( ) Cell ( ) Pager ( )
Contact person: Email:
TENANT:
PROJECT DESCRIPTION:
Total valuation (cost) $
Area of work/Addition: sf
Existing building size: sf
# of stories:
# residential units:
Type of construction:
Occupancy type:
Fire sprinklers: Hazardous materials:
Describe existing use:
Describe proposed new use:
Approved by Planning Department by: _____________________________________________________________ Date: _______________________
Page 1 of 2
August 2013
ELECTRICAL PERMIT #B - EL________--___________
MECHANICAL PERMIT #B - ME________--___________
PLUMBING PERMIT #B - PL________--___________
Same as Applicant
Same as Applicant
Same as Applicant
CONTRACTOR :
Yes
No
Residential Commercial
APPLICANT:
Same as Applicant
DESIGNER
Name/Company: License Number:
Address: City: State Zip
Phone ( ) Fax ( ) Cell ( ) Pager ( )
Contact person: Email:
Name/Company:
Address: City: State Zip
Phone ( ) Fax ( ) Cell ( ) Pager ( )
Contact person: Email:
Name/Company: License Number:
Address: City: State Zip
Phone ( ) Fax ( ) Cell ( ) Pager ( )
Contact person: Email:
Name/Company:
Address: City: State Zip
Phone ( ) Fax ( ) Cell ( ) Pager ( )
Contact person: Email:
YES
NO
License Class:
License Numer:
Office Use :
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.
License Class: License No.: Contractor Signature: ______________________________________ Date: ________________
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: _________________________________________
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: ________________
WORKERS' COMPENSATION DECLARATION
Carrier:
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 of Applicant: _________________________________________________________________________________ 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: Lender's Address:
CERTIFICATION, AGREEMENT AND AUTHORIZATION
Policy Number:
Expiration Date:
Name of Agent: Phone:
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:
I certify that I have read this application and state that the information is correct. I agree to comply with all city and county ordinances and state laws relating
to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant: ____________________________________ Print Name: ____________________________________ Date: ________________
August 2013
Page 2 of 2
Complete this page prior to permit issuance . Please proceed to Hazardous Material/ Waste Disclosure form.
CITY OF MILPITAS
Building & Safety Department
455 E. Calaveras Blvd.
Milpitas, CA 95035
408-586-3240
www.ci.milpitas .ca.gov
DATE:
BUILDING PERMIT #B -
OWNER-BUILDER
ACKNOWLEDGEMENT
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.
Property Owner's Signature: ___________________________________________________________________________ Date: __________________
NOTICE TO PROPERTY OWNER
When the Owner-Builder Declaration on the permit application is executed, a Notice to Property Owner (below) also shall be executed by the
property owner. The Notice to Property Owner pursuant to this section shall be completed and signed by the property owner and returned prior
to issuance of the permit. An agent of the owner shall not execute this notice. A permit shall not be issued unless the property owner complies
with this section.
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at
____________________________________________. We are providing you with an Owner-Builder Acknowledgment and Information
Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this
form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior
approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
____1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an “Owner-Builder” building permit that
erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable
and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property.
My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of
my insurance coverage for injuries to workers on my property.
____2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are
not hiring a licensed Contractor to assume this responsibility.
____3. I understand as an “Owner-Builder” I am the responsible party of record on the permit. I understand that I may protect myself from
potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own.
____4. I understand Contractors are required by law to be licensed and bonded inCalifornia and to list their license numbers on permits and
contracts.
____5. I understand if I employ or otherwise engage any persons, other thanCalifornia licensed Contractors, and the total value of my
construction is at least five hundred dollars ($500), including labor and materials, I may be considered an “employer” under state and federal
law.
____6. I understand if I am considered an “employer” under state and federal law, I must register with the state and federal government,
withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each “employee.”
I also understand my failure to abide by these laws may subject me to serious financial risk.
____7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot
legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures
does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor.
August 2013
Page1 of 2
____8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal
injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials.
____9. I understand I may obtain more information regarding my obligations as an “employer” from the Internal Revenue Service, the United
States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also
understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more
information about licensed contractors.
____10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and
financially responsible for proposed construction activity at the following address: _______________________________________________.
____11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and
requirements that govern Owner-Builders as well as employers.
____ 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on
this form.
Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the
Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only
remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as
Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the
status of their workers' compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible
for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is
required to be presented when the permit is issued to verify the property owner's signature.
Property Owner's Signature: ___________________________________________________________________________ Date: __________________
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
When the Permit Application and the Owner-Builder Declaration have been executed by a person other than the property owner, prior to issuing the
permit, the following shall be completed by the property owner and returned to the agency responsible for issuing the permit:
Excluding the Notice to Property Owner (below), the execution of which I understand is my personal responsibility, I hereby authorize the following
person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent :
Phone Number of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and
certify its accuracy.
Property Owner's Signature: ________________________________________________________________________ Date: __________________
Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is
required to be presented when the permit is issued to verify the property owner's signature.
August 2013
Page 2 of 2
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Completed 24 May 2022

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