Fillable Development Permit Application (City of Long Beach California)

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Development Permit Application (City of Long Beach California)

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The Development Permit Application (City of Long Beach California) form is 19 pages long and contains:

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  • 156 check-boxes
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U.S.A. forms for City of Long Beach California

BROWSE CITY OF LONG BEACH CALIFORNIA (CA) FORMS

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Page 1 of 1
Development Permit Application
Submittal Instructions
1. Complete pages 1-8 of the application as thoroughly as possible. Please note that in most cases,
including those for minor projects, not all the application pages will need to be filled out, but all
pages of the application must be submitted.
2. Complete the California License Contractor’s Declaration and Owner-Builder’s Declaration found on
pages 9-10, if applicable and depending on WHO requests or pays for the Permit.
➢ If the application is being submitted by a contractor, a copy of a current Contractor’s State License
number, and a copy of an active City of Long Beach Business License will be required. To apply or
renew an existing City of Long Beach Business License, please call (562) 570-6211 or email
Lbbiz@longbeach.gov.
➢ If the application is being submitted by an agent of a contractor, the agent must provide a notarized
Letter of Authorization from the licensed contractor dated within the last year. The letter should be
written on the contractor’s company letterhead and authorize the agent (a person, not a business)
to obtain the permit(s) on their behalf
3. Complete the Owner-Builder Permit Proxy Form found on pages 11-12, if applicable.
➢ If application is being submitted by an Authorized Agent of the Property Owner, the Agent must
complete the Authorization of Agent to Act on Property Owner’s Behalf section at the bottom of the
form.
4. Email the completed application package, along with any required construction documents (e.g., Plans,
Plot Plans, and/or Site Plans) that may apply to your project, to:
DV-BuildingSafety@longbeach.gov.
➢ For details and instructions on how to prepare your construction documents and the pertinent
information that is required, please go to Plan Review Services.
➢ For details and instructions on how to submit projects through the Email Over the Counter (EOTC)
process, please go to Project Plan Submittal and Review Service.
When the application, including any required documents has been received, the permit will be
processed. You will then be directed via email to the Development Services Cashier to pay your
permit fees and any other relevant fees over the phone.
Please read the Submittal Instructions below carefully to ensure that your application is complete
and includes all relevant details pertaining to your project. Please note incomplete applications
and required forms can further delay the processing of your permit and/or plan submittal. The
application, including this page, contains a total of 13 pages. The applicant will either be the
Contractor, Architect (Designer), Property Owner-Builder or their Authorized Agent.
When the application, including any required documents, has been submitted, it will be reviewed
and then a permit will be processed. You will then be directed via email to the Development
Services Cashier to pay your permit fees and any other relevant fees over the phone.
Development Services
Building and Safety Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.PMIT (7648)
Page 1 of 12
(I/We) the undersigned declare, under penalty of perjury under the laws of the State of California, that (I am/we are) the owner(s)
or authorized representative(s) of the property in this application; that the information on all plans, drawings, and sketches
attached hereto and all the statements and answers contained herein are, in all respects, true and correct.
SIGNATURE
PRINT NAME
DATE
General Information
PROJECT NUMBER
Authorization
Plan Check Permit Tech
PROJECT ADDRESS (NOT MAILING ADDRESS) PROJECT NAME (IF ANY)
LEGAL DESCRIPTION (i.e. Lot, Block, Tract, APN, etc.)
DOING BUSINESS AS (DBA) SUBMITTAL DATE
APPLICANT LAST NAME, FIRST NAME OWNER DESIGN PROFESSIONAL
AGENT FOR LESSEE/TENANT
CONTRACTOR
APPLICANT MAILING ADDRESS EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
1) DESIGN PROFESSIONAL LAST NAME, FIRST NAME
ARCHITECT
CIVIL
STRUCTURAL
OTHER
DESIGN PROFESSIONAL MAILING ADDRESS DESIGN PROFESSIONAL EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
2) DESIGN PROFESSIONAL LAST NAME, FIRST NAME
ARCHITECT
CIVIL
STRUCTURAL
OTHER
DESIGN PROFESSIONAL MAILING ADDRESS DESIGN PROFESSIONAL EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
PROPERTY OWNER LAST NAME, FIRST NAME
PROPERTY OWNER MAILING ADDRESS EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
DESCRIPTION OF WORK
Development Permit Application
Development Services
Building & Safety Bureau
411 W. Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.PMIT (7648) | longbeach.gov/lbds
click to sign
signature
click to edit
Building
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
BUILDING PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
PROJECT SCOPE (CHECK ALL BOXES THAT APPLY)
NEW CONSTRUCTION ALTERATION/REMODEL/TENANT IMPROVEMENT ADDITION CHANGE OF USE/OCCUPANCY
TYPE OF CONSTRUCTION PRESENT USE/OCCUPANCY PROPOSED USE/OCCUPANCY
# DWELLING UNITS # OF STORIES BUILDING HEIGHT CBC EDITION USED
FIRE SPRINKLERS
YES NO
FIRE ALARM
YES NO
FIRE STANDPIPES
YES NO
SMOKE CONTROL
YES NO
GRADING PERMIT (IN CUBIC YARDS)
CUT: __________ FILL: __________ EXPORT: __________ IMPORT: __________
Fire
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
FIRE PROJECT NUMBER
Same as Building Project Number
CONTRACTOR LAST NAME, FIRST NAME STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
QTY
ITEM
QTY
ITEM
FIRE ALARM VALUATION: $____________________________ FIRE ALARM SYSTEM DEVICES
FIRE ACCESS UNDERGROUND STORAGE TANK
UNDERGROUND FIRE LINE UNDERGROUND STORAGE TANK PIPING (FT)
SPRINKLERS RISERS VAPOR RECOVERY SYSTEM
SPRINKLER HEADS ABOVEGROUND STORAGE
STANDPIPE SYSTEM HOSE VALVES ABOVEGROUND STORAGE TANK PIPING (FT)
SPECIAL FIRE EXT. SYSTEM NOZZLES OTHER___________________________________
Page 2 of 12
New
VALUATION COVERED BY APPLICATION
$
SQUARE FOOTAGE OF PROJECT:
OFFICE USE ONLY
RESIDENTIAL
Remodel/
Additions
NON-RESIDENTIAL
Demolition/
Removal
New
Construction
Remodel/
Additions
Demolition/
Removal Construction
Existing: ______________________________
New/Add/Remodel: _____________________
Demolition/Removal: ____________________
Health
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
HEALTH PROJECT NUMBER
Same as Building Project Number
CONTRACTOR LAST NAME, FIRST NAME STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
FOOD FACILITY
ITEM
ITEM
ITEM
RESTAURANT # OF SEATS _____
BED & BREAKFAST
GREASE TRAP
SCHOOL CAFETERIA
FOOD MRKT RETAIL (SQ. FT.)
FOOD PROCESSOR (SQ. FT.)
SATELLITE FACILITY/KIOSK
CATERER
CONSULTATION MENU CHANGE/EQUIPMENT
FOOD VEHICLE
WAREHOUSE/COMMISSARY
FOOD CART
SALVAGER
OTHER _____________________
BACKFLOW
FOOD FACILITY POOL & SPA OTHER_____________________
WATER SYSTEMS
CROSS CONNECTIONS /
RECYCLED WATER
NEW POOL REMODEL/REPLASTER – POOL
NEW SPA REMODEL/REPLASTER – SPA
SEWAGE DISPOSAL SYSTEM
MINOR REMODEL / EQUIP
CHANGE – POOL
MINOR REMODEL / EQUIP
CHANGE – SPA
BODY ART
TATTOO SHOP
OTHER _____________________
Page 3 of 12
LOW IMPACT DEV SYSTEM
WITH ONSITE WTR REUSE
LOW IMPACT DEV SYSTEM
WITHOUT ONSITE WTR REUSE
Electrical
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
ELEC PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME Same as Building Cont STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
PROJECT SCOPE (CHECK ALL BOXES THAT APPLY)
NEW CONSTRUCTION ALTERATION/REMODEL/TENANT IMPROVEMENT ADDITION CHANGE OF USE/OCCUPANCY
TYPE OF CONSTRUCTION PRESENT USE/OCCUPANCY PROPOSED USE/OCCUPANCY
# DWELLING UNITS # OF STORIES BUILDING HEIGHT CEC EDITION USED
VALUATION COVERED BY APPLICATION
$
QTY
SERVICE
QTY
MOTORS, GENERATORS,
TRANSFORMERS & OTHER
APPARATUS
QTY BUSWAYS, POWER DUCTS
≤ 600 V SERVICE ≤ 200 AMPS
< 1 HP, KW, KVA
FEET OF BUSWAY ≤ 99 AMP
≤ 600 V SERVICE 201 – 400 AMP
1-10 HP, KW, KVA FEET OF BUSWAY 100-400 AMP
≤ 600 V SERVICE
401 – 1000 AMP
11-50 HP, KW, KVA FEET OF BUSWAY > 400 AMP
≤ 600 V SERVICE > 1000 AMP
51-100 HP, KW, KVA
QTY
SIGNS (NEW OR ALTERATION)
1
ST
SIGN AND SIGN CIRCUIT
> 600 V SERVICE > 100 HP, KW, KVA ADDITIONAL SIGN CIRCUIT(S)
1
ST
SB OR MCC ≤ 600 V
NEW RESIDENTIAL SQ. FOOTAGE
OF FLOOR AREA
ADDITIONAL SIGN(S)
1
ST
SB OR MCC > 600 V
QTY
OUTLETS AND FIXTURES
TEMPORARY POLE
WITH
PANEL (EXCLUDING SERVICE)
NUMBER OF OUTLETS/OPENINGS
ADDITIONAL METERS # BUILDING LIGHTING FIXTURES
1ST OUTLETS ≤ 50
ADDITIONAL SB OR MCC
≤ 600 V
MULTI-OUTLET/FIXTURE
ASSEMBLIES (EACH 5' OR PORTION
THEREOF)
TEMPORARY OUTLETS > 50
ADDITIONAL SB OR MCC > 600 V
QTY SPEC OUTLETS (INDIV CIRCUITS) QTY PHOTOVOLTAIC SYSTEMS
15-30 AMP RESIDENTIAL KILOWATTS
PANELS (SUBPANELS AND/OR
CONTROL PANELS)
31-50 AMP / EVC* COMMERCIAL KILOWATTS
# OUTSIDE/PARKING LIGHTING
STANDARDS
51-100 AMP
> 100 AMP
FOR OFFICE USE ONLY
# SQ FT FOR TITLE 24 REVIEW
* EVC – Electric Vehicle Charger / Application qualifies for expedited installation services.
Page 4 of 12
Mechanical
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
MECH PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME Same as Building Cont STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
PROJECT SCOPE (CHECK ALL BOXES THAT APPLY)
NEW CONSTRUCTION ALTERATION/REMODEL/TENANT IMPROVEMENT ADDITION CHANGE OF USE/OCCUPANCY
TYPE OF CONSTRUCTION PRESENT USE/OCCUPANCY PROPOSED USE/OCCUPANCY
# DWELLING UNITS # OF STORIES BUILDING HEIGHT CMC EDITION USED
QTY ITEM QTY ITEM QTY ITEM
HEATING APPLIANCE
WOOD BURNING APPLIANCE
APPLIANCE/CHIMNEY/VENT
AIR INLET/OUTLET
SMOKE/FIRE DAMPER
SMOKE DETECTOR
AIR COND COMP
≤
25 HP
AIR COND COMP 26-50 HP
AIR COND COMP > 50 HP
GAS/STEAM FIRED AIR COND
UNIT
EVAPORATIVE COOLER OR MAKE
UP AIR UNIT
FAN COIL/AIR HANDLER*
COMMERCIAL HOOD
COMMERCIAL COOKING DUCT
PRODUCT CONVEY VENT**
COOLING TOWER
BATH/KITCHEN/DRYER DUCT
PIPING SYSTEM
REFRIGERATION COMP
≤
25 HP
REFRIGERATION COMP 26-50 HP
REFRIGERATION COMP > 50 HP
ABSORPTION UNIT
BOILER < 1,000K BTU
BOILER
≥
1,000K BTU
ALTER/ADD SYSTEM
TITLE 24 ENERGY REVIEW
OTHER _____________________
FOR OFFICE USE ONLY
# SQ FT FOR TITLE 24 REVIEW
*Requires 1 Piping System & Air Handler **Commercial/Industrial/Garage Exhaust
Note: Vav Box Is No Charge
Page 5 of 12
Plumbing
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
PLMB PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME Same as Building Cont STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
PROJECT SCOPE (CHECK ALL BOXES THAT APPLY)
NEW CONSTRUCTION ALTERATION/REMODEL/TENANT IMPROVEMENT ADDITION CHANGE OF USE/OCCUPANCY
TYPE OF CONSTRUCTION PRESENT USE/OCCUPANCY PROPOSED USE/OCCUPANCY
# DWELLING UNITS # OF STORIES BUILDING HEIGHT CPC EDITION USED
QTY ITEM QTY ITEM QTY ITEM QTY ITEM
TOILETS BACKFLOW < 2"
GAS, DRAIN, VENT
ALTER/REPAIR
1.5" – 2” WATER LINE
SINKS BACKFLOW > 2"
GAS METER
RELOCATION
2.5" – 4” WATER LINE
BATHTUB BACKWATER VALVE
GAS PRESSURE
REGULATOR
≥ 5" WATER LINE
GARBAGE
DISPOSER
FIRE HOSE OULET GAS SYSTEM
DISABLED ACCESS
FIXTURES
AUTOMATIC
WASHER
HOSE BIBBS MED/HIGH GAS METER INDUSTRIAL WASTE
FLOOR DRAIN ON LOT SEWER
REPIPE GAS/WATER
FIXTURE
WET STANDPIPE
SHOWER
SPRINKER
(ANTISIPHON VALVE)
REPIPE WATER
SERVICE ONLY
MED PRESSURE GAS
SYSTEM
DISHWASHER SUMP PUMP AREA DRAIN COMBO WASTE/VENT
DRINKING
FOUNTAIN
TRAP PRIMERS ROOF DRAIN
2" FUEL GAS PIPING
SYSTEM
FLOOR SINK VACUUM BREAKERS PLANTER DRAIN
2.5" – 4" FUEL GAS
PIPING SYSTEM
LAVATORY WATER HEATER
GREASE
INTERCEPTOR
≥
5" FUEL GAS PIPING
SYSTEM
LAUNDRY TRAY
WATER PRESSURE
REGULATOR
SAND INTERCEPTOR MISC. FIXTURES
URINAL
TITLE 24 ENERGY
REVIEW
OTHER INTERCEPTOR OTHER _______________
FIXTURE
CHANGE OUT
Page 6 of 12
Landscape & Irrigation
SUBMITTAL TYPE
REGULAR EXPEDITED OTC NR
PLMB PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
PROJECT SCOPE (CHECK ALL BOXES THAT APPLY)
RESIDENTIAL
NON-RESIDENTIAL
NEW INSTALLATION
REHABILITAITON
TOTAL LANDSCAPE AREA
SQ FT
SPECIAL LANDSCAPE AREA
SQ FT
TURF AREA
SQ FT
NON-TURF PLAN AREA
SQ FT
WATER TYPE:
LONG BEACH WATER OTHER:____________________________________________
WATER TYPE:
COMPLIANCE METHOD
POTABLE
WELL
RECYCLED
OTHER________________
PERFORMANCE PRESCRIPTIVE
ITEM
ITEM
ITEM
ITEM
RESIDENTIAL
PLAN CHECK
RESIDENTIAL
INSPECTION
NON-RESIDENTIAL
PLAN CHECK
NON-RESIDENTIAL
INSPECTION
Page 7 of 12
FOR DEPARTMENT USE ONLY
ZONE
HISTORIC APPROVAL REQ’D
YES NO
RELATED PLANNING CASE NO.
SPECIAL SETBACKS
YES NO
PLANNING FEES REQ’D
YES NO
COASTAL FEE (CPCE) REQ’D
YES NO
SETBACKS
PLANNING REVIEW (PLAN CHECK) REQ’D
YES NO
PLANNING ENTITLEMENTS
INCOMPLETE (Not ready for Plan Check Submittal)
COMPLETE NOT REQUIRED
F
S
R
CF TO PL
ZONING CLEARANCE (INIT) & DATE
PLANNING APPR (INIT) & DATE
SUBMITTAL TYPE
REGULAR EXPRESS OTC NR
Planning
SUBMITTAL TYPE
REGULAR OTC NR
PLANNING PROJECT NUMBER
ITEM
ITEM
ITEM
ADMINISTRATIVE U
SE PERMIT (AUP)
SUBDIVISION M
AP
SITE PLAN REVIEW
(SPR) # OF FEET ____
CONDITIONAL US
E PERMIT (CUP)
LOT MERGER/LOT LINE
ADJUSTMENT
CONCEPTUAL ONLY
PRE-APPLICATION ONLY
WIRELESS TELECOM
STANDARDS VARIANCE (SV) CERTIFICATE OF COMPLIANCE
FENCE HEIGHT EXCEPTION (AUP or SV) CONDOMINIUM CONVERSION
MODIFICATION
OF APPROVED PERMIT
ZONING CHANGE AND/OR
AMENDMENT
CREATIVE SIGN
PERMIT
TIME EXTENSION
LOCAL COASTAL PROGRAM
AMENDMENT
SIGN PROGRAM
LOCAL COASTAL DEVELOPMENT PERMIT
GENERAL PLAN AMENDMENT
CONDO CONVERSION EXCLUSION
# OF UNITS ______
GENERAL PLAN CONFORMITY
FINDING
OTHER ________
Sign
SUBMITTAL TYPE
REGULAR OTC NR
SIGN PROJECT NUMBER
CONTRACTOR LAST NAME, FIRST NAME STATE LICENSE NO. & TYPE EXP. DATE
CONTRACTOR MAILING ADDRESS CONTRACTOR EMAIL ADDRESS
CITY STATE ZIP PHONE FAX
CITY BUSINESS LICENSE # (IF KNOWN) EXP. DATE TYPE OF BUSINESS CITY PIN
ELECTRICAL*
YES / NO
SIGN TYPE VALUE SQUARE FEET OVERALL HEIGHT ABOVE
GRADE
1
2
3
4
5
6
7
8
TOTAL VALUATION OF ALL SIGNS:
FOR DEPARTMENT USE ONLY
N = NEW E = EXISTING D = DEMOLISH/REMOVE A = ADD/EXPAND
PLANNING APPROVAL BY PLAN STAMPED YES NO DATE
*If signs require electrical hook-up, an electrical permit will also be required.
Page 8 of 12
Address: Project #:
1. 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 and Address
State Contractor’s License No. and Class Contractor Signature
Long Beach Business License Number Expiration Date
2. 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 Exp 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.
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
($100,000.00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706
OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
3. VERIFICATION OF APPLICATION, LAW COMPLIANCE AND INSPECTION ACCESS.
By my signature below, I certify to each of the following:
• 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.
I am (__) the California licensed contractor or (__) authorized agent acting on the contractor’s behalf.
California Licensed Contractor:
Signature Date
Contractor’s Authorized Agent:
Name (print) Signature Date
Address of Authorized Agent
4. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY
California Licensed Contractor's Declaration
and Owner-Builder's Declaration
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
5. CONTRACTOR PERMIT PROXY
If the Contractor does not carry worker’s compensation insurance and is not available to personally complete the permit
application at the Long Beach City Hall, the above information may be completed and signed by the licensed contractor
and submitted by proxy. The application declarations must be completely filled out and signed by the contractor in three
(3) appropriate places (California Licensed Contractor’s Declaration, Worker’s Compensation Declaration and Verification
of application, Law Compliance and Inspection Access). In addition to completing the above information, the
contractor must provide a copy of the front and back of the signed contractor’s state license card. Please note
that the license holder must sign the reverse side of the state licensed card.
Page 9 of 12
Development Services
Building & Safety Bureau
411 W. Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.PMIT (7648) | longbeach.gov/lbds
Address: Project #:
1. 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).
(_) 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
2. 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 Exp 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.
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
($100,000.00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706
OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
3. 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
By my signature below, I certify to each of the following:
• I have read this construction permit application and the information I have provided is true and correct.
• I agree to comply with all applicable Long Beach City, 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.
I am (__) the property owner or (__) authorized agent acting on the property owner’s behalf.
The Notice to Property Owner form shall accompany this document. The property owner must complete the Authorization of Agent
section on the form when an authorized agent is acting on the property owner’s behalf.
Signature Date
To request this information in an alternative format or to request a reasonable accommodation, please contact the
Development Services Department at longbeach.gov/lbds and 562.570.3807. A minimum of three business days
is requested to ensure availability; attempts will be made to accommodate requests with shorter notice.
Page 10 of 12
Owner-Builder Permit Proxy Form
NOTICE TO PROPERTY OWNER
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 in California and to list their license numbers on
permits and contracts.
____5. I understand if I employ or otherwise engage any persons, other than California 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.
____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.
Page 11 of 12
Development Services
Building & Safety Bureau
411 W. Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.PMIT (7648) | longbeach.gov/lbds
____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.
Signature of property owner ___________________________________________ Date: __________________
__________________________________________________________________________
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER’S BEHALF
Excluding the Notice to Property Owner, 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: _________________________________________Tel No ___________________
Address 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. 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.
Property Owner’s Signature: _______________________________________ Date: _____________________
Page 12 of 12
To request this information in an alternative format or to request a reasonable accommodation, please contact the
Development Services Department at longbeach.gov/lbds and 562.570.3807. A minimum of three business days
is requested to ensure availability; attempts will be made to accommodate requests with shorter notice.
Long Beach Development Services
411 W. Ocean Blvd., 3rd Floor
Long Beach, CA 90802
Visit us at longbeach.gov/lbds
Email us at lbds @longbeach.gov
To request this information in an alternative format or to request a reasonable accommodation, please contact the
Development Services Department at longbeach.gov/lbds and 562.570.3807. A minimum of three business days
is requested to ensure availability; attempts will be made to accommodate requests with shorter notice.
@LongBeachBuilds
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Development Permit Application (City of Long Beach California)

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Completed 23 January 2021

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