|
JOB ADDRESS: PERMIT#:
<br /> Cl�
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby-affirm that I am licensed under-the provisions of Chapter 9(commencing with Section 7000)of Division 3 of-the Business
<br /> and,'Pr ofes'gio'n's Code and my liceiiseis in full force and effect, 1,
<br /> License# �k2 be 5—S—C 9Expiration Date- Y
<br /> Date I , .,.Contractor
<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 r'equ' ires 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 herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a peirnit subjects
<br /> the applicant to a..civil penalty of not more than five hundred dollars($500)):
<br /> 13 1, 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 or 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,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> 0 1, 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 CAtractor'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 /> K t i%,_
<br /> 13 1 am exempt under Section B&PC for this reason
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I heErebaffirm that I have a certificate of consent to self-insure, a certificate of Workers' CompensationInsurance, certified
<br /> Trim
<br /> J p Ise VDID -
<br /> I rCo I
<br /> P III lat Mi omp
<br /> if
<br /> le
<br /> 13 C ified cop s her s
<br /> , . 4- A
<br /> R2 V N �11
<br /> _T
<br /> ❑Certified copy is filed with the Envirorirnental 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 /> 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
<br /> become subject to the Workers' Compensation Laws of California,
<br /> 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 comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender' Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 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, scaffolding,..falsework, or.demolition or dismantling
<br /> thereof, will be more than thirty-six (3.6) feet high. (Chapter 3.2, Group 2, Article 2, Section' 341, Title 8,-Califomia Administrative
<br /> Code).
<br /> E3 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 /> 13 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 constructio ram hereby author' representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> 1-Y
<br /> t
<br /> Date e_ Ap�pifican -4;
<br /> EHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> 12111/2002
<br />
|