X
$432
7/28/23MC APL23-012
x PLNB55588
Attachment N
I hereby affirm that I am licensed under provisions of Chapter 9 {Commencing with Section 7000} of Division 3 of the Business and Professional Code, and my license is I certify that I have read this application and state that the above information is correct. I agree to comply with all City and State laws relating to the building construction, and hereby authorize representatives of this city to enter upon the
LICENSED CONTRACTORS DECLARATION WORKER'S COMPENSATION DECLARATION ● I am exempt under
Sec.
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:
License
ClassDat
e
License
No. Contract
orOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason {Sec .7031 California Business and Professional Code: Any City 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 is a licensed contractor pursuant to the provisions of the Contractors License Law {Ch .9} {Commencing with Sec .7000 of Div.3 of the B. & P. C.} or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sec .7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars {$500.00}.:
● 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 or offered for sale {Sec.7044, B. & P. C. : The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvements is sold within one year of completion, the owner -builder will have burden of proving that he did not build or improve for the - IMPORANT -
Application is hereby made to the Superintendent of Building and Safety for a permit subject to the conditions and restrictions set forth on the front faces of this application
1. Each person upon whose behalf this application is made and each person at whose benefit work is performed under or pursuant to any permit issued as a result of this application agrees to and shall indemnify and hold harmless the City of Long Beach its officers, agents, and employees from any liability arising out of the issuance of any permit from this application.
2. Any permit issued as a result of this application becomes null and void if work is , B. & P. C. for this
reasonDat
e
Owne
r
Carrier: Policy
Number:
{This Section need not be completed if the permit is for one hundred dollars ($100) or less} 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 Dat
e
Applica
nt
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, IN ADDITION
TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR IN SECTION Lender's
Name
Lender's
Address
DateSignature of Owner or Contractor
I hereby state that there is a construction lending agency for the performance of the work for which this permit is issued {Sec.3907, Civ. C.}.
JOB ADDRESS RECEIPT NO. DATE PROJECT NO.
JOB DESCRIPTION AREA
PLANNINGOCCUPANCYOWNER
ADDRESS
CITY STATE ZIP CODE
APPLICANT
CONTRACTOR
ADDRESS
CITY STATE ZIP CODE
STATE LICENSE NO.
ARCHITECT/ENGINEER
ADDRESS
CITY STATE ZIP CODE
VALUATION
PHONE NO.
LEGAL DESCRIPTION
PRESENT BLDG USE PROPOSED BLDG USE BLDG HEIGHT TYPE OF CONSTRUCTION LICENSE NO.
CITY LICENSE NO.
PHONE NO.
FSB S RSB CENSUS TRACT
ZONEASSESSOR NO.
6615 PACIFIC COAST HWY
0.00 Paid by: ELIZABETH LAMBE
$432.00 Credit or Debit Card (PC)
PLNB55588
0 APPTHPTY
ELIZABETH LAMBE
Regional Serving Facility
SP-2-MUCC
980007
0 7/31/2304291493
Application Number 2208-10 APL23-012 Third-party appeal of Planning Commission dec
Appeal by Third Party 400.00 24222158
Surcharge General Plan N 16.00 24222159
Surcharge Technology N 16.00 24222160
432.00 CHECK