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SECTION I - UNIT INFORMATION43785lBC4E4KUAm95531 J .)FeeLicense Class .Lie. No. Exp. Dale. Contractor .Date Date Decal Number 2. QWNER-BIJILDER DECLARATION AA No. RT TG RT BY Year of Manufacture. Insignia / HUD Label Mumber(s). CL Lh B. 8. P C. tor this reason:Address. L\City..Zip.Owner.Date. Telephone - Applicant.3. WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: SECTION 3 - CONTRACTOR, ARCHITECT OR ENGINEER INFORMATION Contractor's Name. Address. Architect / Engineer Name. Carrier Registration No. Policy Number Address SECTION 4 - DESCRIPTION OF WORK / ACTIVITY AND VALUATION Applicant Date. 4, CONSTRUCTION LENDING AGENCY Indicate the Total Cost of the Work Io be Performed. Lender's Nome Lender's Address. q 115 CERTIFICATION Signature Date. •'•DEPARTMENT USE ONLY” Permit Expiration Date CONDITIONS (see reverse side) Dale: Signature of Applicant or Agent Date ilosed / Signature of District Representative HCD415 (Rev. 07/20131 WHITE-AREA OFFICE PINK - OWNER/APPLICANTDISTRIBUTION:YELLOW-DEPARTMENT SPCM I cerfily that I have 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 Io building construction and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Manufactured Home/Mobilehome Mullifamily Manufactured Home Commercial Modular (Occupancy Group Special Purpose Commercial Modular I / We are requesting services for the following unit(s): (Check Appropriate Box) -Zip-OS-Mff C2-»"Vc3^te''loM State of California Business. Transportation and Housing Agency /TENT OF HOUSING AND COMMUNITY DEVELOPMENT Division of Codes and Standards Serial Number(s) / VIN Number ZJ F) -<CTQ Manufacturer Name / Model Name? Pn/?r> romnuflr' ifli Vm _______ DTN / Permit No. 76^1 DISAPPROVED (see reverse side) 1\Q -1^ /D/O^S Date APPROVED Issued By: Describe the proposed work / activity in detail. Attach additional pages if necessary. Where structural alterations or additions are proposed, complete plans, specifications, details, and calculations are required to be attached to this form. Provide the make and model of any appliance to be installed and provide complete electrical calculations for any electrical alternations or additions. ISec. 7044. Business and Professions Code: The Contractors' License Law does not apply to on owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors' License Law.). 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. HCD 415 APPLICATION FOR Alternate Approval Technical Services Inspection To Obtain Insignia I hereby affirm under penalty of perjury thal there Is a construclion lending agency for the performance of the work for which this permit is issued (Section 3097. Civil Code). SECTION 5 - SIGNATURE AND CERTIFICATION I / We hereby makexrpplicdltion for the services designated above.>7^ [ | 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 workers' compensation laws of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions I hereby affirm under penalty of perjury that I am exempt from the Contractors' License Law for the following reason: [ J I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 ol the Labor Code, for the performance of the work for which this permit is issued. SELLER a SEI County jy-\ -Av SECTION 2 - OWNER / APPLICANT INFORMATION Owner------- Address,. ICS'^.q___ City-----^XOOG-A^-H.County Location Address / 3>l-‘ Ca (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 work himself or herself or through his or her own employees, provided that such - 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 hear she did not build or improve for the purpose of sale.). I 1 I. as owner of the property, am exclusively contracting with licensed contractors Io construct the project Park Ngpie (If Applicable)Park ID#. Applican I V) Homeowner (If Different than Applicant) [ | 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 ncieuy ui>ini> uouo po..o.., x.. p_.,u., ,— . _____ _ 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. ( j I am exempt under Sec. onflSJON OF CODES AND STANDARDS AS EVIDENCED BY THIS INSIGNIA THE MANUFACTURER CERTIFIES TO COMPLIANCE WITH THE CA HEALTH AND SAFETY CODE DDL 13, PART 2 AND CA CODE OF REGULATIONS TULE 25, CHAPTER 3 FOR SPECIAL PURPOSE COMMERCIAL MODULAR CONSTRUCTION. A SPECIAL PURPOSE COMMERCIAL MODULAR BEARING A DEPARTMENT INSIGNIA SHALL NOT HAVE ITS FIRE AND LIFE SAFETY, PLUMBING, ELECTRICAL, OR MECHANICAL EQUIPMENT OR INSTALLATIONS ALTERED OR CONVERTED UHlESSAfPROVAL IS FIRST OBTAINED FROM THE DEPARTMENT. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' License Law 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 permit subjects the applicant Io a civil penally 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 the work, and the structure is not intended of offered for sale.