Fill - Free fillable ELECTRONIC APPLICATION FOR BUILDING PERMIT City of Hemet (City of Hemet) PDF form

Permit Application Electronic 2020.docx

City of Hemet

Department of Building and Safety

ELECTRONIC APPLICATION FOR

BUILDING PERMIT

NOTE: 3 sets of plans and specifications for residential construction or 5 sets of plans and specifications

for commercial construction must be submitted.

Property Address: Date:

Assessor Parcel Number: Lot Number: Valuation:

Description of Work:

Construction Type: SFR Mobile Home Multi-Family: ___ # Units Commercial

Property Owner: Applicant:

Address: Address:

City: State: Zip: City: State: Zip:

Telephone: ( ) - Telephone: ( ) -

CONTRACTOR INFORMATION: LICENSED DESIGN PROFESSIONAL:

Name: Name:

Address: Address

City: State: Zip: City: State: Zip:

Telephone: ( ) - Telephone:( ) -

Fax: ( ) - License Number: Expiration Date:

Contact Person: Telephone: ( ) - Email:

State License Number: Type: Expiration Date:

Contractor’s Workers Comp. Ins. Carrier: Number: Exp. Date:

Contractors City Business License Number: Expiration Date:

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 Signature _______________________________________________________________________

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 HUNDREAD

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. ___________________________

Plan Check #:

Permit Application Electronic 2020.docx

_____ I have and will maintain worker’s compensation insurance, as required by Section 3700 of the Labor Code, for

the performance of the work for which this permit is issued. My worker’s compensation insurance carrier and policy

number are: Name of Agent ________________________ Phone #: _________________

Carrier____________________ Policy Number ___________________ Expiration Date _______________

_____ 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

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 Contractor’s State License Law does not apply to an owner of property who, through employee’s 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

I was not built or improved for the purpose of the sale.).

(__) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section

7044, Business and Professions Code: The Contractor’s State License Law does not apply to an owner of property who

builds or improves thereon, and who contracts for the projects with 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

Date: ___________ Signature of Property Owner or Authorized Agent ______________________________

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: _________________________________

By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property’s

behalf. I have read this application and the information I 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/or Authorized Agent Signature: ______________________________ Date: ____________

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