|
JOB ADDRESS: PERMIT#•
<br /> i
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I herebyaffirmthat I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code-and 1my.license is in full force and effect. ,A 4 r,% �,{ ', • !- i
<br /> License# it t
<br /> Expiration Date A t
<br /> i
<br /> f�
<br /> Date=�f�, ? '� �'`� - Contractor
<br /> OWNER-BUILDER DECLARATION 1
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> a permit to construct, alter, improve, demolish, or repair any structureprior to
<br /> Professions Code: Any city or county which'requires
<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 permit subjects r
<br /> 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 s"cture 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 /> 5 fJ
<br /> ❑ 1, as owner_of the property, am exclusively contracting with licensed contractors to construct the•project (Section 7044, Business V�
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to ali-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 /> \ : h ,
<br /> ❑I am exempt under Section B&PC for this reason 7 `* #
<br /> Date: Owner r.
<br /> V,
<br /> WORKERS' COMPENSATION DECLARATION i h
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers' Com ensation insur nce,or y d
<br /> ccR�e
<br /> Mh
<br /> it to mpan
<br /> ❑Ce tied copy ` U I
<br /> W
<br /> 13 Certified copy is filed with the Environmental Health Department t
<br /> i
<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 /> 1 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 L
<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 /> f
<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 /> 14 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, scaffolding, falsework, 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 air ell city and county
<br /> ordinances and state laws relating to well construction and or sewage system cons"rrtie Zr, amend hey authorize re rese tittives of this
<br /> county to enter u�on the above-mentioned property for inspection purposes. r
<br /> Date Applicant U ��
<br /> EHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> 12/11/2002
<br />
|