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City of Ojai

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401 S. Ventura St. 93023 Ojai, CA 93023 (805) 646-5581

BUILDING PERMIT APPLICATION

SITE INFORMATION

BUILDING TYPE CONST

PROJECT ADDRESS ASSESSOR'S ASSESSOR’S PARCEL NO.

ZONE

OWNER

PHONE

MAIL ADDRESS

MOBILE PHONE

OWNER REPRESENTATIVE or TENANT

PHONE

MAIL ADDRESS

MOBILE PHONE

CONTRACTOR CONTACT PERSON

MOBILE PHONE

ARCHITECT or ENGINEER

STATE LICENSE NO.

MAIL ADDRESS

PHONE

ARCHITECT or ENGINEER CONTACT PERSON

MOBILE PHONE

Rev. 12/29/15

OCCUP GRP

STORIES

BLDG HT.

DESCRIPTION

LEGAL DECLARATIONS LICENSED CONTRACTORS DECLARATION hereby affirm affirm that that II am amlicensed licensed under under provisions provisions of of Chapter Chapter 99 (commencing (commencing with with I hereby Section 7000) Professions Code, Section 7000) of Division Division 3 of the Business and Professions Code, and and my license license is is in full force and effect. License Number: _______________________________

License Class: ____________

SIZE OF BUILDING X = ___________________ SQ. FT. SIZE OF GARAGE X = ___________________ SQ. FT. PORCHES, PATIO, COVERING xX = ___________________ SQ. FT. TOTAL VALUATION $

VALUATION VALUATION VALUATION

PERMIT/ PERMIT / ISSUING ISSUING FEE FEE $

PLAN CHECK FEE $

BUILDING STANDARDS FEE $

TECHNICAL SURCHARGE FEE $

ENERGY FEE $

ENERGY PLAN CHECK FEE $

ACCESSIBILTY FEE $

ACCESSIBILTY PLAN CHECK FEE $

GREEN BUILDING CODE FEE $

GREEN BUILDING CODE PLAN CHECK FEE $

HIGH FIRE FEE $

HIGH FIRE PLAN CHECK FEE $

PARK FEE $

STATE SEISMIC FEE $

Contractor Name & Address: _______________________________________________ _______________________________________________________________________

IDENTIFY WORKER’S WORKER'S COMPENSATION COVERAGE WARNING: FAILURE FAILURE TO SECURE SECURE WORKER'S WORKER’S COMPENSATION COMPENSATION COVERAGE COVERAGE IS UNLAWFUL, UNLAWFUL, AND AND SUBJECT AN EMPLOYER EMPLOYER TO CRIMINAL PENALTIES PENALTIES AND ONE HUNDRED HUNDRED SHALL SUBJECT AND CIVIL CIVIL FINES UP TO ONE THOUSAND DOLLARS ($100,000), ($100,000), IN IN ADDITION THOUSAND DOLLARS ADDITION TO THE THE COST COST OF OF COMPENSATION, COMPENSATION, DAMAGES DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY FEES. WORKERS’ COMPENSATION DECLARATION WORKERS'

OTHER FEE $

PENALTY FEE $

GENERAL PLAN MAINTENANCE FEE $

I hereby affirm under penalty of perjury one of the following declaration:

( ) I have have and and will will maintain maintain aa certificate certificate of of consent consent to to self-insure self-insure for for workers' workers’ compensation, Industrial Relations Relations as provided provided for by Section Section compensation, issued issued by by the Director of Industrial 3700 of the Labor Code, for the performance of the work for which this permit is issued.

PLUMBING WATER CLOSET DISHWASHER

Policy No. ___________________________________________________________________ ( ) )I Ihave haveand andwill willmaintain maintainworkers' workers’compensation compensation insurance, insurance, as required by Section 3700 Code, for the performance performance of work for which which the permit is issued. issued. My 3700 of the Labor Code, of the the work worker’s compensation compensation insurance insurance carrier carrier and policy number are: workers

Carrier: _________________________________ Policy No. __________________________

CLOTHES WASHER

SYSTEMS

LAVATORY

BATH /SHOWER

FLOOR DRAIN

LAUNDRY TUB

NO.

GARBAGE DISPOSAL WATER HEATER

SIZE, ETC. size.

COST EACH

SINK

FEE $ FEE $

GAS PIPING PRIVATE SEWAGE DISPOSAL SYSTEM SEWER –- HOUSE HOUSE LINE

Expiration Date: ______________________________________________________________ Name of Agent: _________________________ Telephone No. ________________________ ( ))IIcertify certifythat, that, in in the the performance performance of of the the work work for for which this permit is issued, I shall not employ any person in any manner manner so so as as to to become become subject subject to to the the workers' workers’ not employ any person in any compensation laws of California, and agree that, if I should should become subject to the workers' workers’ compensation compensation provision provision of of Section Section 3700 3700 of the Labor Code, I shall forthwith comply with those provisions.

DECLARATON REGARDING CONSTRUCTION LENDING AGENCY

WATER SYSTEM CITY MAIN SEWER

PERMIT FEE $

MECHANICAL HEATING HEATING //COOLING COOLING

NO.

SIZE , ETC.

COST EACH I

FEE $

hereby affirm affirm under under penalty penalty of perjury perjury that there there is is aa construction construction lending lending agency agency for the I hereby performance of the work for which this permit is issued (Section 8172, Civil Code) Lender’s Lender's Name: ___________________________________________________ Branch Designation: ________________________________________________

PERMIT FEE $

Lender’s Lender's Address: __________________________________________________________

ASBESTOS NOTIFICATION

()

Yes Air Pollution Control District Approval (approval provided) No (( ) I declare that notification of asbestos removal is not applicable to addressed project

ELECTRICAL SERVICES

NO.

VOLTS

AMPS

FEE $

EQUIP OR MISC

NO.

RATING

COST EACH

$ FEE S

DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to each of the following: I am:

(( ) a California Licensed Contractor Theproperty propertyOwner* Owner*and andhave havesubmitted submittedProperty Property Owner Owner Verification Verification ( )) The Authorizedtotoact acton onthe theproperty property owner's owner’s behalP* behalf** ( )) Authorized

construction permit application and the information I have provided is correct. II I have read this construction agree to comply with all applicable city and county ordinances and state laws relating to building construction. county to to enter enter the theabove-identified above-identified construction. II authorize authorize representatives representativesofof this this city city or county property for inspection purposes.

* requires separate verification form ** requires separate authorization form THIS PERMIT BECOMES NULL AND VOID IF IF WORK WORK OR OR CONSTRUCTION CONSTRUCTION AUTHORIZED AUTHORIZED IS NOT 180 DAYS, OR NOT READY READY FOR FOR INITIAL INITIAL INSPECTION INSPECTION WITHIN WITHIN 180 OR IF IF CONSTRUCTION CONSTRUCTION OR OR SUSPENDED OR ABANDONED ABANDONED FOR TIME AFTER AFTER WORK IS SUSPENDED FOR A PERIOD OF 180 DAYS ANY TIME WORK IS COMMENCED. SIGNATURE OF OWNER, CONTRACTOR or AUTHORIZED AGENT:

_________________________________________ Date: ___________________

PERMIT FEE $ COUNTY TRAFFIC FEE $

PLAN FILING FEE $

CITY TRAFFIC FEE $

ZONING CLEARANCE $

ALLOCATION FEE $

AMT DUE FOR PERMIT $

DRAINAGE FEE $

CHECK NO.

NAME ON CHECK OR CREDIT CARD: PREPARED BY: ISSUED BY:

DATE PREPARED: ISSUE DATE: