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Site Address: ________Rancho Mirage, California 92270
Residential OR Commercial Description of WorkEst. 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: ________
\"Image\"\" 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.
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Project Cost: $______", "html_text": "Est. Project Cost: $______", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 2, "location": [ 38.88, 574.32, 576.96, 595.84 ], "cells": [ { "location": [ 38.88, 574.32, 218.24, 595.84 ], "text": "New Construction (including ADUs) ✿\nLiving Area (inc. A/C.) Sq. Ft.: ________", "html_text": "New Construction (including ADUs) ✿\nLiving Area (inc. A/C.) Sq. Ft.: ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 218.24, 574.32, 576.96, 595.84 ], "text": "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: ________", "html_text": "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: ________", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 3, "location": [ 38.88, 552.8, 576.96, 574.32 ], "cells": [ { "location": [ 38.88, 552.8, 218.24, 574.32 ], "text": "Add. /Expansion Existing Structure, Sq. Ft. ________", "html_text": "Add. /Expansion Existing Structure, Sq. Ft. ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 218.24, 552.8, 576.96, 574.32 ], "text": "Re-Roofing\nPool/Spa\nWindow Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "html_text": "Re-Roofing\nPool/Spa\nWindow Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 4, "location": [ 38.88, 531.28, 576.96, 552.8 ], "cells": [ { "location": [ 38.88, 531.28, 218.24, 552.8 ], "text": "Conversion (e.g. Garage to living), Sq. Ft. ________", "html_text": "Conversion (e.g. Garage to living), Sq. Ft. ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 218.24, 531.28, 576.96, 552.8 ], "text": "Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "html_text": "Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 5, "location": [ 38.88, 509.76, 576.96, 531.28 ], "cells": [ { "location": [ 38.88, 509.76, 218.24, 531.28 ], "text": "Demolition, Sq. Ft. ________", "html_text": "Demolition, Sq. Ft. ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 218.24, 509.76, 576.96, 531.28 ], "text": "Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "html_text": "Window Replacement, Enlarging opening? Yes/No\nPV Solar/Battery, Upgrading Existing: Yes/No\nSystem Size: ________ Battery: ________", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 6, "location": [ 38.88, 488.24, 576.96, 509.76 ], "cells": [ { "location": [ 38.88, 488.24, 218.24, 509.76 ], "text": "Other: ________", "html_text": "Other: ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 218.24, 488.24, 397.6, 509.76 ], "text": "", "html_text": "", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 397.6, 488.24, 576.96, 509.76 ], "text": "System Size: ________", "html_text": "System Size: ________", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 7, "location": [ 38.88, 466.72, 576.96, 488.24 ], "cells": [ { "location": [ 38.88, 466.72, 576.96, 488.24 ], "text": "Note: Covered projects require the CALGREEN minimum 65% diversion of C&D material. No. Mods: ________ No. Inverters: ________", "html_text": "\"Image\" Note: Covered projects require the CALGREEN minimum 65% diversion of C&D material. No. Mods: ________ No. Inverters: ________", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 3, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 8, "location": [ 38.88, 445.2, 576.96, 466.72 ], "cells": [ { "location": [ 38.88, 445.2, 576.96, 466.72 ], "text": "a separate C&D Waste Management Plan must be submitted and approved prior to permit issuance.", "html_text": "a separate C&D Waste Management Plan must be submitted and approved prior to permit issuance.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 3, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" } ], "n_rows": 9, "n_cols": 3, "ref": "#/tables/0", "reading_order": 5 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 108.655, "t": 641.454, "r": 368.619, "b": 622.727 }, "text": "☐Residential OR ☐ Commercial", "field_kind": "text", "label": "☐Residential OR ☐ Commercial", "pdf_field_name": "Text1", "pdf_field_type": "Text", "reading_order": 6 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 463.42, "t": 621.817, "r": 573.493, "b": 602.436 }, "text": "Site Address: _______________________________________________ Rancho Mirage, California 92270", "field_kind": "text", "label": "Site Address: _______________________________________________ Rancho Mirage, California 92270", "pdf_field_name": "Text4", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 41.2365, "t": 615.927, "r": 55.3092, "b": 601.854 }, "text": "Description of Work", "field_kind": "checkbox", "label": "Description of Work", "pdf_field_name": "Check Box2", "pdf_field_type": "CheckBox", "reading_order": 8 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 128.291, "t": 615.927, "r": 139.746, "b": 601.854 }, "text": "INFORMATION", "field_kind": "checkbox", "label": "INFORMATION", "pdf_field_name": "Check Box3", "pdf_field_type": "CheckBox", "reading_order": 9 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 161.673, "t": 607.417, "r": 572.838, "b": 585.417 }, "text": "☐New Construction (including ADUs)", "field_kind": "text", "label": "☐New Construction (including ADUs)", "pdf_field_name": "Text2", "pdf_field_type": "Text", "reading_order": 10 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 329.892, "t": 585.49, "r": 342.656, "b": 572.072 }, "text": "☐HVAC Installation/Replacement", "field_kind": "checkbox", "label": "☐HVAC Installation/Replacement", "pdf_field_name": "Check Box13", "pdf_field_type": "CheckBox", "reading_order": 11 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 42.2184, "t": 585.163, "r": 54.3274, "b": 571.09 }, "text": "Living Area (inc. 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Ft.: ___________", "pdf_field_name": "Text6", "pdf_field_type": "Text", "reading_order": 13 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 329.892, "t": 570.817, "r": 342.656, "b": 557.399 }, "text": "☐Electrical Upgrade/New Panel/Sub Panel", "field_kind": "checkbox", "label": "☐Electrical Upgrade/New Panel/Sub Panel", "pdf_field_name": "Check Box14", "pdf_field_type": "CheckBox", "reading_order": 14 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 221.892, "t": 558.981, "r": 290.073, "b": 545.49 }, "text": "☐Add. /Expansion Existing Structure, Sq. Ft. __________", "field_kind": "text", "label": "☐Add. /Expansion Existing Structure, Sq. Ft. __________", "pdf_field_name": "Text7", "pdf_field_type": "Text", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 329.892, "t": 555.49, "r": 342.656, "b": 542.072 }, "text": "☐Water Heater Installation/Replacement", "field_kind": "checkbox", "label": "☐Water Heater Installation/Replacement", "pdf_field_name": "Check Box15", "pdf_field_type": "CheckBox", "reading_order": 16 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 254.619, "t": 544.581, "r": 313.637, "b": 529.126 }, "text": "☐Conversion (e.g. Garage to living), Sq. Ft. ____________", "field_kind": "text", "label": "☐Conversion (e.g. Garage to living), Sq. 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Name:
Telephone No.:
Email Address:
Mailing Address:
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No. _____________Bus Lic. No. _______________", "field_kind": "text", "label": "Lic. No. _____________Bus Lic. 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No. ___Bus Lic. No. ___\nTelephone No.: ___", "reading_order": 52 }, { "page": 1, "type": "TEXT", "location": { "l": 327.6, "t": 376.56, "r": 580.32, "b": 363.12 }, "text": "Telephone No.:", "reading_order": 53 }, { "page": 1, "type": "TEXT", "location": { "l": 327.36, "t": 359.04, "r": 579.12, "b": 345.6 }, "text": "Email Address: ___\nMailing Address: ___", "reading_order": 54 }, { "page": 1, "type": "TEXT", "location": { "l": 327.36, "t": 341.28, "r": 577.44, "b": 327.36 }, "text": "Mailing Address:", "reading_order": 55 }, { "page": 1, "type": "TEXT", "location": { "l": 327.84, "t": 323.04, "r": 578.64, "b": 309.6 }, "text": "___", "reading_order": 56 }, { "page": 1, "type": "TITLE", "location": { "l": 277.44, "t": 291.84, "r": 352.56, "b": 279.36 }, "text": "CERTIFICATION", "reading_order": 57, "level": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 90, "t": 265.68, "r": 542.88, "b": 242.64 }, "text": "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.)", "reading_order": 58 }, { "page": 1, "type": "TEXT", "location": { "l": 97.68, "t": 233.76, "r": 540, "b": 222.24 }, "text": "Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth.", "reading_order": 59 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 55.68, "t": 215.04, "r": 568.8, "b": 187.68 }, "text": "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.", "marker": "1.", "list_id": "L1", "level": 0, "reading_order": 60 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 57.6721, "t": 183.968, "r": 562.2071, "b": 173.77 }, "text": "Any permit issued as a result of this application becomes null and void if work is not commenced within ONE HUNDRED EIGHTY", "marker": "2.", "list_id": "L1", "level": 0, "reading_order": 61 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 57.6001, "t": 173.168, "r": 263.3132, "b": 162.97 }, "text": "DAYS from the date of issuance of such permit.", "marker": "(180)", "list_id": "L1", "level": 0, "reading_order": 62 }, { "page": 1, "type": "TEXT", "location": { "l": 42, "t": 152.88, "r": 582.72, "b": 109.44 }, "text": "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.", "reading_order": 63 }, { "page": 1, "type": "TEXT", "location": { "l": 173.52, "t": 90.24, "r": 294, "b": 79.92 }, "text": "Date: __/____/____ Name:", "reading_order": 64 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 196.365, "t": 100.579, "r": 273.055, "b": 78.579 }, "text": "SIGN", "field_kind": "text", "label": "SIGN", "pdf_field_name": "Page 1 Date", "pdf_field_type": "Text", "reading_order": 65 }, { "page": 1, "type": "TEXT", "location": { "l": 268.8, "t": 90, "r": 450.72, "b": 79.92 }, "text": "___", "reading_order": 66 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 294.165, "t": 98.761, "r": 448.747, "b": 78.724 }, "text": "Date: ____/____/______ Name: __________________________________", "field_kind": "text", "label": "Date: ____/____/______ Name: __________________________________", "pdf_field_name": "Page 1 Name", "pdf_field_type": "Text", "reading_order": 67 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 173.455, "t": 78.597, "r": 449.129, "b": 46.597 }, "text": "_____________________________________________________________", "field_kind": "signature", "label": "_____________________________________________________________", "pdf_field_name": "Page 1 Signature", "pdf_field_type": "Signature", "reading_order": 68 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TITLE", "location": { "l": 158.64, "t": 695.52, "r": 490.08, "b": 679.44 }, "text": "BUILDING PERMIT- ASSIGNMENT & ISSUANCE", "reading_order": 0, "level": 1 }, { "page": 2, "type": "TEXT", "location": { "l": 42, "t": 660, "r": 236.16, "b": 649.2 }, "text": "Site Address: ___", "reading_order": 1 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 104.073, "t": 666.327, "r": 432.11, "b": 647.599 }, "text": "Site Address: ____________________________________________ _____________________ Rancho Mirage, CA 92270", "field_kind": "text", "label": "Site Address: ____________________________________________ _____________________ Rancho Mirage, CA 92270", "pdf_field_name": "Text1", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 2, "type": "TITLE", "location": { "l": 82.56, "t": 636.72, "r": 237.84, "b": 625.92 }, "text": "OWNER-BUILDER DECLARATION", "reading_order": 3, "level": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 44.4, "t": 615.12, "r": 291.36, "b": 519.36 }, "text": "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).", "reading_order": 4 }, { "page": 2, "type": "TEXT", "location": { "l": 48, "t": 516.96, "r": 290.88, "b": 498.96 }, "text": "I hereby affirm under penalty of perjury, one of the following declarations (SELECT ONE):", "reading_order": 5 }, { "page": 2, "type": "TEXT", "location": { "l": 44.64, "t": 488.16, "r": 291.84, "b": 408.72 }, "text": "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's License 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.)", "reading_order": 6 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 29.291, "t": 492.053, "r": 45.982, "b": 477.326 }, "text": "their sole compensation, will do the work and the structure is", "field_kind": "checkbox", "label": "their sole compensation, will do the work and the structure is", "pdf_field_name": "Check Box24", "pdf_field_type": "CheckBox", "reading_order": 7 }, { "page": 2, "type": "TEXT", "location": { "l": 44.4, "t": 403.92, "r": 291.84, "b": 355.44 }, "text": "I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, B&PC: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)", "reading_order": 8 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 28.9637, "t": 406.635, "r": 45.0002, "b": 391.907 }, "text": "I, as owner of the property, am exclusively contracting with", "field_kind": "checkbox", "label": "I, as owner of the property, am exclusively contracting with", "pdf_field_name": "Check Box25", "pdf_field_type": "CheckBox", "reading_order": 9 }, { "page": 2, "type": "TEXT", "location": { "l": 47.04, "t": 348.72, "r": 286.56, "b": 338.16 }, "text": "I am exempt under Sec. _____, of B&PC for this reason:", "reading_order": 10 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 138.11, "t": 356.071, "r": 187.309, "b": 336.689 }, "text": "Contractor’s License Law.)", "field_kind": "text", "label": "Contractor’s License Law.)", "pdf_field_name": "Text28", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 2, "type": "TEXT", "location": { "l": 38.16, "t": 345.36, "r": 289.68, "b": 260.64 }, "text": "I am exempt under Sec. ___, of B&PC for this reason:", "reading_order": 12 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 29.6183, "t": 353.616, "r": 46.3093, "b": 336.925 }, "text": "I am exempt under Sec. __________, of B&PC for this reason:", "field_kind": "checkbox", "label": "I am exempt under Sec. __________, of B&PC for this reason:", "pdf_field_name": "Check Box26", "pdf_field_type": "CheckBox", "reading_order": 13 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 38.6183, "t": 336.434, "r": 288.11, "b": 318.362 }, "text": "_______________________________________________________", "field_kind": "text", "label": "_______________________________________________________", "pdf_field_name": "Text29", "pdf_field_type": "Text", "reading_order": 14 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 37.9096, "t": 317.652, "r": 287.401, "b": 299.58 }, "text": "_______________________________________________________", "field_kind": "text", "label": 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"field_kind": "text", "label": "_______________________________________________________", "pdf_field_name": "Text33", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 2, "type": "TITLE", "location": { "l": 430.56, "t": 660.48, "r": 553.2, "b": 648.96 }, "text": "Rancho Mirage, CA 92270", "reading_order": 19, "level": 3 }, { "page": 2, "type": "TITLE", "location": { "l": 392.64, "t": 643.68, "r": 511.92, "b": 631.68 }, "text": "LICENSED CONTRACTOR", "reading_order": 20, "level": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 326.64, "t": 627.6, "r": 577.68, "b": 602.4 }, "text": "I hereby affirm that I am 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.", "reading_order": 21 }, { "page": 2, "type": "TEXT", "location": { "l": 326.64, "t": 596.88, "r": 576.96, "b": 586.56 }, "text": "Name: ___", "reading_order": 22 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 355.46, "t": 602.85, "r": 574.066, "b": 587.719 }, "text": "(Sec.7031.5 California Business and Professions Code(B&PC)):", "field_kind": "text", "label": "(Sec.7031.5 California Business and Professions Code(B&PC)):", "pdf_field_name": "Text34", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 2, "type": "TEXT", "location": { "l": 326.4, "t": 582, "r": 576.48, "b": 570.96 }, "text": "Lic. 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Date: ___", "reading_order": 27 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 368.697, "t": 571.964, "r": 451.992, "b": 555.362 }, "text": "that he/she is licensed pursuant to the provisions of the", "field_kind": "text", "label": "that he/she is licensed pursuant to the provisions of the", "pdf_field_name": "Text37", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 2, "type": "TEXT", "location": { "l": 326.88, "t": 551.04, "r": 576.96, "b": 540.24 }, "text": "Address: ___", "reading_order": 29 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 363.55, "t": 556.521, "r": 575.536, "b": 539.184 }, "text": "Div. 3 of the B&PC) or that he/she is exempt therefrom and the", "field_kind": "text", "label": "Div. 3 of the B&PC) or that he/she is exempt therefrom and the", "pdf_field_name": "Text38", "pdf_field_type": "Text", "reading_order": 30 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 330.09, "t": 539.975, "r": 575.904, "b": 524.844 }, "text": "by any applicant for a permit subjects the applicant to a civil", "field_kind": "text", "label": "by any applicant for a permit subjects the applicant to a civil", "pdf_field_name": "Text39", "pdf_field_type": "Text", "reading_order": 31 }, { "page": 2, "type": "TEXT", "location": { "l": 327.36, "t": 520.08, "r": 576.96, "b": 509.52 }, "text": "Rep.: _____ Tel. No.: _____", "reading_order": 32 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 484.298, "t": 525.351, "r": 576.725, "b": 509.484 }, "text": "Rep.: ______________________ Tel. No.: ____________________", "field_kind": "text", "label": "Rep.: ______________________ Tel. No.: ____________________", "pdf_field_name": "Text41", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 347.739, "t": 524.164, "r": 451.948, "b": 508.297 }, "text": "I hereby affirm under penalty of perjury, one of the following", "field_kind": "text", "label": "I hereby affirm under penalty of perjury, one of the following", "pdf_field_name": "Text40", "pdf_field_type": "Text", "reading_order": 34 }, { "page": 2, "type": "TEXT", "location": { "l": 327.84, "t": 504.48, "r": 576.72, "b": 493.44 }, "text": "Email: ___", "reading_order": 35 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 353.388, "t": 508.987, "r": 576.07, "b": 493.774 }, "text": "I, as owner of the property, or my employees with wages as", "field_kind": "text", "label": "I, as owner of the property, or my employees with wages as", "pdf_field_name": "Text42", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 2, "type": "TITLE", "location": { "l": 331.44, "t": 484.08, "r": 584.16, "b": 471.84 }, "text": "WORKER'S COMPENSATION DECLARATION (AB-443)", "reading_order": 37, "level": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 322.08, "t": 465.6, "r": 564.72, "b": 449.28 }, "text": "I hereby affirm under penalty of perjury, one of the following declarations (SELECT ONE):", "reading_order": 38 }, { "page": 2, "type": "TEXT", "location": { "l": 328.8, "t": 449.52, "r": 578.4, "b": 401.52 }, "text": "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 forthwith comply with those provisions.", "reading_order": 39 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 312.801, "t": 448.326, "r": 330.801, "b": 430.326 }, "text": "permit is issued, I shall not employ any person in any manner", "field_kind": "checkbox", "label": "permit is issued, I shall not employ any person in any manner", "pdf_field_name": "Check Box2", "pdf_field_type": "CheckBox", "reading_order": 40 }, { "page": 2, "type": "TEXT", "location": { "l": 330.72, "t": 396.48, "r": 577.68, "b": 362.88 }, "text": "I have and will maintain a certificate 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.", "reading_order": 41 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 312.492, "t": 394.544, "r": 330.492, "b": 376.544 }, "text": "for workers’ compensation, as provided for by Sec. 3700 of the", "field_kind": "checkbox", "label": "for workers’ compensation, as provided for by Sec. 3700 of the", "pdf_field_name": "Check Box3", "pdf_field_type": "CheckBox", "reading_order": 42 }, { "page": 2, "type": "TEXT", "location": { "l": 330.96, "t": 358.08, "r": 577.92, "b": 324 }, "text": "I have 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:", "reading_order": 43 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 313.147, "t": 356.271, "r": 331.147, "b": 338.271 }, "text": "required by Sec. 3700 of the Labor Code, for the performance", "field_kind": "checkbox", "label": "required by Sec. 3700 of the Labor Code, for the performance", "pdf_field_name": "Check Box4", "pdf_field_type": "CheckBox", "reading_order": 44 }, { "page": 2, "type": "TEXT", "location": { "l": 322.56, "t": 312.24, "r": 576, "b": 301.92 }, "text": "Carrier: ___", "reading_order": 45 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 353.716, "t": 316.222, "r": 576.398, "b": 301.01 }, "text": "Carrier: _________________________________________________", "field_kind": "text", "label": "Carrier: _________________________________________________", "pdf_field_name": "Text43", "pdf_field_type": "Text", "reading_order": 46 }, { "page": 2, "type": "TEXT", "location": { "l": 322.8, "t": 296.88, "r": 575.52, "b": 286.08 }, "text": "Policy: ___", "reading_order": 47 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 354.37, "t": 299.859, "r": 577.052, "b": 284.646 }, "text": "_______________________________________________________", "field_kind": "text", "label": "_______________________________________________________", "pdf_field_name": "Text44", "pdf_field_type": "Text", "reading_order": 48 }, { "page": 2, "type": "TEXT", "location": { "l": 323.04, "t": 274.56, "r": 574.08, "b": 262.08 }, "text": "Date: ___/___/___ Applicant: ___", "reading_order": 49 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 456.875, "t": 286.689, "r": 575.456, "b": 261.889 }, "text": "SIGN", "field_kind": "signature", "label": "SIGN", "pdf_field_name": "Signature5", "pdf_field_type": "Signature", "reading_order": 50 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 346.911, "t": 280.143, "r": 418.365, "b": 264.034 }, "text": "_______________________________________________________", "field_kind": "text", "label": "_______________________________________________________", "pdf_field_name": "Workers Comp Date", "pdf_field_type": "Text", "reading_order": 51 }, { "page": 2, "type": "TEXT", "location": { "l": 34.8, "t": 223.92, "r": 287.76, "b": 213.84 }, "text": "Date: ___/___/___ Owner: ___", "reading_order": 52 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 149.892, "t": 239.561, "r": 288.764, "b": 212.143 }, "text": "SIGN", "field_kind": "signature", "label": "SIGN", "pdf_field_name": "Owner Builder Signature", "pdf_field_type": "Signature", "reading_order": 53 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 60.1642, "t": 230.27, "r": 131.618, "b": 214.161 }, "text": "Date: ____/____/______ Owner: ____________________________", "field_kind": "text", "label": "Date: ____/____/______ Owner: ____________________________", "pdf_field_name": "Owner Builder Date", "pdf_field_type": "Text", "reading_order": 54 }, { "page": 2, "type": "TEXT", "location": { "l": 33.6, "t": 211.92, "r": 289.44, "b": 200.88 }, "text": "
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\n", "reading_order": 55 }, { "page": 2, "type": "TEXT", "location": { "l": 327.36, "t": 247.44, "r": 571.44, "b": 183.84 }, "text": "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.", "reading_order": 56 }, { "page": 2, "type": "TITLE", "location": { "l": 267.84, "t": 173.28, "r": 342.24, "b": 162 }, "text": "CERTIFICATION", "reading_order": 57, "level": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 33.6, "t": 153.36, "r": 578.16, "b": 99.12 }, "text": "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.", "reading_order": 58 }, { "page": 2, "type": "TEXT", "location": { "l": 167.76, "t": 78.24, "r": 253.2, "b": 67.68 }, "text": "Date: ___/___/___\nName: ___", "reading_order": 59 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 191.728, "t": 84.288, "r": 263.183, "b": 68.1787 }, "text": "Date: ____/____/______ Name: __________________________________", "field_kind": "text", "label": "Date: ____/____/______ Name: __________________________________", "pdf_field_name": "Date1_af_date 2", "pdf_field_type": "Text", "reading_order": 60 }, { "page": 2, "type": "FIGURE", "location": { "l": 207.84, "t": 78, "r": 236.64, "b": 67.68 }, "text": "", "reading_order": 61 }, { "page": 2, "type": "TEXT", "location": { "l": 262.08, "t": 77.76, "r": 447.36, "b": 68.16 }, "text": "
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