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State of California o�ssrrc Business,Transportation and Housing Agency +t DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT n Division of Codes and Standards 3Gat HCD 415 APPLICATION FOR ❑Alteration ❑ Addition or Conversion ❑ Alternate Approval ❑ Technical Services binspection To Obtain Insignia CONTRACTOR/OWNER-BUILDER DECLARATIONS SECTION T-UNIT INFORMATION Not required for Special Purpose Commercial Modular I/We are requesting services for the following unit(s): - 1 LICENSED CONTRACTORS DECLARATION r g 9 ! (Check Appropriate Box) I hereby affirm under penalty of pedury that I am licensed;under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions ❑ Manufactured Home/Mobilehome DTN/Permit No. Code and my license is in full force and effect. 13 Multifamily Manufactured Home ❑ Commercial Modular(OccupancyGroup_ ) L License Class Lic.No. Exp.Date Fee ',�pecial Purpose Commercial Modular Contractor —Do}e J ecal Number Date / 1'D 2.OWNER-BUILDER DECLARATION - / 1 hereby affirm under penalty of perjury that I am exempt from the Contractors' Serial Number(s) License Law for the following reason: f U �� VIN Number AA NO. '`7 ! (Sec.7031.5,Business and Professions Code: Any city or ctounty which requires a permit RT TO to construct alter,improve,demolish,or repair any structure,prior to its issuance,also Manufacturer Name/Model Name I e LA t requires the applicant for such permit to file a signet statement that he or she is RT BY - t-n1✓1 licensed pursuant to the provisions of the Contractors' License Low Chapter 9 �� ' (commencing with Section 7000 of Division 3 of the Business and Professions Code)or that he or she Is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perr)iit subjects the applicant to a civil Year of Manufacture j penalty of not more than five hundred dollars($500)) Insignia/HUD Label Number(s) [ ] 1, asowner of the property, or my employees with wages as their sole compensation,will do the work,and the structure is not intended of offered for sale. SECTION 2-OWNER/APPLICANT INFORMATION (Sec. 7044, Business and Professions Code: The.Contractors'License Law does not apply to an owner of property,who builds or Improves thereon,and who does such Owneij. work himself or herself or through his or her own employees, provided that such %1 f c: improvements are not intended or offered for sale. If, however, the building or Address int im ro r A — burd' he City f`vA 11-(:' l""i_, e!'54'CCounty r V. ZI STATE OF CALIFORNIA d con Department of Housing&Community Development Location Address (Sec Division of Codes and Standards to C FI L INSPECTION CERTIFICATION h Park Name(If Applicable) Park ID# pro] BY: , Ci v' Y YL/ DATE: C ll� Applicant -5c 1�w, District Representative) (ID No.) Address LABOR DATA: AREA:❑ North ❑ South County No: Owl _ City County rp PCAIACTCOD r U /U �- TRMtLES Telephone-Applicant Homeowner TIME:INSPIACT �� C> TRAVEL TIME Of Different than Applicant] con SECTION 3-CONTRACTOR,ARCHITECT OR ENGINEER INFORMATION INSPECTION DATA: Private Property 13 MH PARK s� pert - Contractor's Name #HOME/UNIT ,l FLOORS -y Address Sec VIOLATIONDATA: TOTAL CORRECTIONS: is issut Architect/Engineer Name Car, S_F—E— M_P_G/O_NP_ Registration No. . Polis FEE COLLECTION AND OTHER INFORMATION: Address _ shal FEES:$ CIC# DATE I SECTION 4-DESCRIPTION OF WORK/ACTIVITY AND VALUATION con ITEMS ISSUED: HCD 59 ❑ Gas ❑Electric ❑I.A.C. con Y with Describe the proposed work/activity in detail. Attach additional pages if necessary. Where ATTACHMENTS:p ? structural alterations or additions are proposed, complete plans, specifications, details, and A PERMIT NO' n,>X G I f Q FILE CLOSED calculations are required to be attached to this form. Provide the make and model of any pp appliance to be installed and provide complete electrical calculations for any electrical WAI !J�r�r - alternations or additions. ANC APPLICANT SIGNATURE DATE HUI�- COI INTEL 4.CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agencyy Indicate the Total Cost of the Work to be Performed for the performance of the work for which this permit is issued (Section 3097, Cfv!1 Code). i SECTION 5-SIGNATURE AND CERTIFICATION Lender's Name I Lender's Address I/We herebyimoke application for the services designated above. 5.CERTIRCATION Signature Date rr I certify that I Bove read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating -DEPARTMENT USE ONLY** to building construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Permit Expiration Date ❑.APPROVED ❑ CONDITIONS(see reverse side) ❑ DISAPPROVED(see reverse side) iT .Issued B • t" (;f Tl �_�S, s - Date- Signature of A licant or Agent Date I 9 PP 9 aZO HCD 415(Rev.07/2013) DISTRIBUTION: YELLOW-DEPARTMENT WHITE-AREA OFFICE PINK-OWNER/APPUCANT