===== PAGE 1 ===== ## BUILDING PERMIT APPLICATION ## PROJECT INFORMATION

Site Address: ________	Rancho Mirage, California 92270
Residential OR Commercial Description of Work	Est. Project Cost: $______
New Construction (including ADUs) ✿\nLiving Area (inc. A/C.) Sq. Ft.: ________	HVAC Installation/Replacement\nElectrical Upgrade/New Panel/Sub Panel\nWater Heater Installation/Replacement\nRe-Roofing\nPool/Spa\nWindow Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________
Add. /Expansion Existing Structure, Sq. Ft. ________	Re-Roofing\nPool/Spa\nWindow Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________
Conversion (e.g. Garage to living), Sq. Ft. ________	Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________
Demolition, Sq. Ft. ________	Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________
Other: ________		System Size: ________
Note: Covered projects require the CALGREEN minimum 65% diversion of C&D material. No. Mods: ________ No. Inverters: ________
a separate C&D Waste Management Plan must be submitted and approved prior to permit issuance.

## OWNER INFORMATION

Name:

Telephone No.:

Email Address:

Mailing Address:

## ARCHITECT/DESIGNER INFORMATION Name: ___ Lic. No. ___Bus Lic. No. ___ Telephone No.: ___ Email Address: ___ Mailing Address: ___ ___ ## CERTIFICATION TRANSPARENCY NOTICE: Some or all of the content contained in this application and its attachments may be subject to disclosure pursuant to the California Public Records Act (Government Code section 6250. et seq.) Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth. 1. Each person upon whose behalf this application is made and each person at whose request and for 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 Rancho Mirage, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within ONE HUNDRED EIGHTY (180) DAYS from the date of issuance of such permit. 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 the City to enter upon the above-mentioned property for inspection purposes. I also understand that utilities will not be released until such times as all laws, codes and special conditions are completed and accepted by the City. By signing this application, I attest that the property owner has granted consent to apply for the permit and that the associated plans can be released to the property owner at any time. Date: __/____/____ Name: ___ ===== PAGE 2 ===== # BUILDING PERMIT- ASSIGNMENT & ISSUANCE Site Address: ___ ## OWNER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason (Sec.7031.5 California Business and Professions Code(B&PC)): 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/she is licensed pursuant to the provisions of the Contractor's License Law (Ch.9 (commencing with Sec. 7000) of Div. 3 of the B&PC) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violations of Sec. 7031.5 by any applicant for a permit subject to the applicant to a civil penalty of not more than five hundred dollars (500.00). Ihereby affirm under penalty of perjury, one of the following declarations (SELECT ONE): 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 PC: The Contractor'sLicense Law does not apply to any 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 improvement is sold within one year of completion, the owner-builder will have the burden of proving he did not build or improve for the purpose of sale.) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, B PC: The Contractor'sLicense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with acontractor(s) licensed pursuant to the Contractor'sLicense Law.) Iam exempt under Sec. ___, of B PC for this reason: Date: ___/___/__Owner: __Date: ___/___/___/__Other: ___ ## Rancho Mirage, CA 92270 ## LICENSED CONTRACTOR Ihereby affirm that Iam licensed 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. Name: __Lic. No.: ____Class: ____Exp. Date: __Address: __Rep.: ____Tel. No.: ____Email: ___ ## WORKER'SCOMPENSATION DECLARATION (AB-443) Ihereby affirm under penalty of perjury, one of the following declarations (SELECT ONE): Icertify that in the performance of the work for which this permit is issued, Ishall not employ any person in any manner so as to become subject to the workers' compensation laws of California and agree that if Ishould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, Ishall forthwith comply with those provisions. Ihave and will maintain acertificate of consent to self-insure for workers' compensation, as provided for by Sec. 3700 of the Labor Code, for the performance of the work for which this permit is issued. Ihave and will maintain workers' compensation insurance as required by Sec. 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: Carrier: __Policy: __Date: ___/___/__Applicant: __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. ## CERTIFICATION 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 the City to enter upon the above-mentioned property for inspection purposes. I also understand that utilities will not be released until such times as all laws, codes and special conditions are completed and accepted by the City. By signing this application, I attest that the property owner has granted consent to apply for the permit and that the associated plans can be released to the property owner at any time. Date: ___/___/___ Name: ___