Form Center

2. 
4. Building Permit Application

   City of Modesto Building Safety

   1010 Tenth Street Suite 3100

   209-577-5232

6. Title II Compliance

   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.

8. Date*
   Date
9. Applicant*
   Enter the name of the PERSON applying for the permit
10. Construction Cost*
    Enter the cost of construction including the price of labor and materials. If there isn't a cost, please enter $200
12. Applicant's Email*
    Enter the APPLICANT"S email address
13. Project Address*
    Enter the address for the project
15. Owner's Last Name*
    Owner's Last Name or the name of the entity owning the property
16. Owner's First Name
17. Owner's Address*
    Enter the owner's address
18. State*
    State
20. Zip*
    Enter the owner's zip code
21. Phone Number*
    Enter the owner's phone number
22. Owner's Email*
    Enter the owner's email address
23. Owner lives at project address

    Check this box if the owner lives at the project address

    1. Yes
    2. No
25. Contractor's Name
    Enter the COMPANY NAME of the contractor
26. Contractor Phone
    Enter the phone number for the contractor
27. License #
    Enter the contractor's license number
28. Business License#
    Enter the BUSINESS license number for the contractor
30. Contractor's Street Address
32. Contractor's City
33. State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
34. Zip Code
36. Designer
    Enter the name of the designer's COMPANY
37. Designer Email
    Enter the designer's email
38. Designer's Phone
    Enter the phone number for the designer
40. Street Address
42. City
43. State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
44. Zip Code
46. Description of Work*
    Enter a brief description of the proposed work
48. 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 county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes
50. Agree?*
    -- Select One --YesNo
52. NAME*
    Enter your name as evidence of making the above certification
54. LICENSED CONTRACTOR'S DECLARATION
    I hereby affirm that I am licensed under the 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. I have secured permission from the property owner to obtain this permit
56. Agree
    -- Select One --YesNo
58. 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 Business and Professions Code: Any city or county 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 or she is licensed pursuant to the provisions of the Contractor’s License Law (Chapter 9, (commencing with Section 7000), of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
60. Owner Builder Selection
    -- 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, Business and Professions Code I, as owner of the property, am exclusively contracting with licensed contractors to construct the project

    If you are the project owner, you must select an option
62. WORKER'S COMPENSATION DECLARATION
    I hereby affirm under penalty of perjury one of the following declarations:
64. DECLARATION*
    -- Select One --I have and will maintain a certificate of consent to self-insure for Workers’ Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work under this permitI 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. 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

    The owner or contractor must make a selection
66. Name*
    Enter Your name as making the above worker's compensation declaration
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67. Print Only

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