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<br /> JOB ADDREss: PERMIT#;
<br /> LICENSED CONTRACTORS DECLARATION �.
<br /> I hereby affum that I am licensed under the provisions of Chapter 9(commcncmg�with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License# - ;w Expiration Date
<br /> Date Contractor
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<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure,prior to
<br /> its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt hcrefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> a the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself o` through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,
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<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section B&PC for this reason
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<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I herebyaffirm that I have a certificate of consent to self-insure,or a certificate of Workers' Compensation Insurance,or a certified
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<br /> SRishe
<br /> or C
<br /> xa om yX P
<br /> ❑ o L=M E
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars,($100)or less)
<br /> FI certify that in the performance of the work for which this permit is issued,I shall not employ any person irf any manner so as to
<br /> become subject to the Workers' Compensation Laws of California:--
<br /> Date:
<br /> alifornia--Date• Applicant
<br /> NOTICE TO 'APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith coil y with such provisions or this permit shall be deemed revoked.
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<br /> CONSTRUCTION LENDING AGENCY iA:-
<br /> ' I hereby affirm that there is a construction lending agency for the perforrnance of the work for which this permit is issued(Section
<br /> 3097, Civil Code).
<br /> i a
<br /> Lender's Name +
<br /> Lender' Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be=made in
<br /> connection with work authorized by the permit, and that no`building structure, sca_ffolding,_false.work, or,demolition-or_dismantling.
<br /> thereof, will be more than thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br /> Code).
<br /> ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> 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
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 12/23/2003
<br /> Water Well Permit Contractor Declaraction 4-02
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