PERMIT NO:  
ON-LINE PERMIT
  
  

INSPECTION REQUEST LINE
(650) 829-6670
PERMIT TYPE
  

PERMIT SUB-TYPE
    

JOB VALUE     
APN     
DESCRIPTION
    
APPLIED DATE

APPROVED DATE

ISSUED DATE
 
Seal    
 
    PERMIT INFORMATION
FEE SUMMARY
    SITE

    APPLICANT

    OWNER

    CONTRACTOR
NOTE: This job copy of this permit shall be kept on the job site to make the required entries thereon. The permit will expire if work is not started in 180 days, is abandoned, or does not receive an inspection for more than 180 days. Additional fees will be collected to renew expired permits. This is a Building Permit when properly filled out, signed and validated, and is not transferable.
LICENSED CONTRACTORS DECLARATION
____ I, hereby affirm that I am licensed under the provisions of Chapter 9 of Division 3 of the Business and Professions Code and my license is in full force and effect.

CONTRACTOR: _______________________
OWNER-BUILDER DECLARATION
____ 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 for sale.

____ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project. All such contractors must obtain a City Business License prior to beginning work.

OWNER: ___________________________
WORKERS COMPENSATION DECLARATION
____ I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers Compensation Insurance.

____ 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.

APPLICANT: _________________________
NOTICE
Please refer to the Conditions related to this permit issuance. If you believe that these Conditions impose any fees, dedications, reservation or other exactions under the California Government Code Section 66000, you are hereby notified that this document constitutes written notice of a statement of the amount of such fees, and/or a description of the dedications, reservations, and other exactions. You are hereby further notified that the 90-day period in which you may protest such fees, dedications, reservations, and other exactions, pursuant to Government Code Section 66020(a), has begun on the date of issuance of this Building Permit, or on the date that you were provided a Notice of Action for this project, whichever is earlier. If you fail to file a protest within this 90-day period complying with all of the requirements of Section 66020, you will be legally barred from later challenging such exactions. THIS PERMIT WILL EXPIRE IF WORK IS NOT STARTED IN 180 DAYS OR IF WORK IS SUSPENDED FOR MORE THAN 180 DAYS OR IF NO INSPECTION IS SCHEDULED FOR MORE THAN 180 DAYS. DO NOT CONCEAL OR COVER ANY CONSTRUCTION UNTIL THE WORK IS INSPECTED AND THE INSPECTION RECORDED ON THE JOB COPY OF YOUR PERMIT. ALL INSPECTION REQUESTS ARE REQUIRED 24 HOURS IN ADVANCE OF THE INSPECTION. ALL WORK PERFORMED UNDER THIS PERMIT MUST CONFORM TO THE APPROVED PLANS AND SPECIFICATIONS FILED BY THE OWNER OR HIS AUTHORIZED AGENT WITH THE BUILDING DIVISION. I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. I (WE) AGREE TO SAVE, INDEMNIFY, HOLD HARMLESS, AND DEFEND THE CITY OF SOUTH SAN FRANCISCO AGAINST LIABILITIES, JUDGMENTS, COSTS, AND EXPENSES WHICH MAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT. I AGREE TO COMPLY WITH ALL LOCAL ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION AND MAKE THIS STATEMENT UNDER PENALTY OF LAW.
SIGNATURE OF APPLICANT OR AGENT  ;_________________________________ DATE    ____________
INSPECTION SUMMARY

Permit Finaled Date:  __________    Inspector Name:  __________________    Signature:  __________________