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INSTRUCTIONS:
<br />Irispection to Obtain Insignia: Complete Sect . 2, 3. 4, 5 and Contractor/Owner-Builder Declaration >mit the application and the required fees to or, the appropriate Area Office listed below. Upo. rurn receipt of your processed application (White Cop,, _ontact the designated Area Office to schedule tr.
<br />inspection date.
<br />Alteration, Addition or Conversion: Complete Sections 1, 2, 3, 4, 5, and Contractor/Owner-Builder Declarations. Submit the completed application and required
<br />fees to the appropriate Area Office listed below. Upon retum receipt of your processed application (White Copy), contact the designated Area Office to schedul
<br />the inspection date.
<br />Technical Services: Complete Sections 1, 2, 3, and 5. Submit the completed application and required fees to the appropriate Area Office listed below. Upon
<br />return receipt of your processed application (White Copy), contact the designated Area Office to schedule an appointment for services.
<br />Southern Area Office Northern Area Office
<br />3737 Main Street, Suite 400 9342 Tech Center Drive #550
<br />Riverside, CA 92501 Sacramento, CA 95826
<br />(9511 782-4420 (916) 255-2501
<br />Alternate Approval: Complete Sections 1, 2, 3,4, and 5. Submit the completed application and required fees to: Department of Housing and Community
<br />Development, Manufactured Housing Section, P.O. Box 31, Sacramento, CA 95812-0031. If you have any questions you may contact thi
<br />Department at (916) 445-3338.
<br />SECTION 1 - UNIT INFORMATION: Check one box to indicate the type of unit for which you are requesting services. If Commercial Coach, als(
<br />indicate the Occupancy Group Code (i.e. B2, E2, Al, etc.) in the space provided. Enter the unit serial number(s). The serial
<br />number(s) can be located on the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or on the
<br />front cross member of the unit. Enter the year the unit was manufactured. Enter the manufacturer's name and/or trade name.
<br />This information can be obtained from the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or
<br />may be designated on the outside of the unit itself. Enter the decal or license number. This number is located on the license plat
<br />issued by DMV or the decal issued by the Department of Housing. Enter the California Insignia Number(s) or HUD Label Number(s
<br />that were issued for this unit, if known.
<br />SECTION 2 - OWNER/APPLICANT INFORMATION: Enter the owner's name(s) and address of the unit. If the address for the owner is different
<br />than the location of the unit, provide that information is the "Location Address" area. If the applicant is other than the owner,
<br />enter the name, address and telephone number of the applicant. The Department will contact or correspond with the party tha
<br />is entered as the-applicant. If the applicant is the same as the owner, the applicant information is not required to be completed,
<br />SECTION 3 - CONTRACTOR, ARCHITECT OR ENGINEER INFORMATION: If the services are being performed by a contractor, enter the
<br />contractor's name and address. Also enter the contractor's license expiration date. If requested services involve an Architect or
<br />Engineer, enter the architect or engineer's name, address and license number.
<br />SECTION 4- DESCRIPTION OF WORK/ACTIVITY AND VALUATION: Provide a description of the work to be performed (i.e., installing a new roof,
<br />installing new windows, etc.) Enter the total cost of the work to be performed (total contact price).
<br />SECTION 5 - SIGNATURE AND CERTIFICATION: The signature of the applicant is required along with the date the form is signed. If the
<br />application is for a replacement insignia or HUD label, the signature must be of the owner of the unit.
<br />CONTRACTOR/OWNER-BUILDER DECLARATIONS
<br />Contractor: Contractors proposing construction are required by state law to provide the following information:
<br />Item 1 - Licensed Contractor Declaration: Enter the contractor's license class, license number, license expiration date and the contractor's signatur
<br />and date.
<br />Item 3- Workers' Compensation Declaration: Place a check mark next to the declaration regarding the workers' compensation coverage that
<br />applies to the contractor. If the second declaration is marked, the contractor must also provide the carrier's name and policy number.
<br />This item must be signed by the contractor and dated.
<br />Item 4- Construction Lending Agency: If there is a construction lending agency for the performance of the work for the service being requested,
<br />enter the name and address of the lending agency. If there is no lending agency involved, enter the word "none".
<br />Item 5- Certification: The certification must be signed and dated by the contractor or and agent on behalf of the contractor.
<br />Owner-Builder: If the work or activity as described on the application, is being completed by the owner, the owner must complete the following
<br />terns:
<br />Item 2 - Owner-Builder Declaration: Place a check mark next to the declaration which is applicable. If the third declaration is marked, enter the
<br />section number from the Business and Profession Code which provides the exemption and the reason for the exemption. The owner must
<br />also sign and date this section.
<br />Item 5- Certification: The certification must be signed and dated by the owner.
<br />DEPARTMENT USE ONLY
<br />APPROVAL OF THIS APPLICATION IS CONDITIONED TO COMPLIANCE WITH REGULATIONS OF THE DEPARTMENT: Any approval issued by the
<br />Department pursuant to this application is conditioned upon the applicant's compliance with the applicable provisions of the California
<br />Administrative Code, Title 25, Chapter 3, and the Business and Professions Code as it relates to contracting.
<br />HCD 415, Side 2 (Rev. 07/20131
<br /> OSP 13 1310(
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