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<br /> JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 4(commencing with Section 7000)of Division 3 of the Business and Professions Code,
<br /> and my license is in full force and effect.
<br /> License H %� '52 ( Exp.:Date
<br /> Date -2 4N Contiactor I
<br /> acti
<br /> OWNER-BUILDER DECLARATION
<br /> 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.7031.5,Business and Professions Code; Any city or
<br /> county which requires it permit!.o construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for suet permit
<br /> to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7(x10)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt hcrc(rom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br /> any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)):
<br /> ❑1,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
<br /> (Sec.7044,Business and Professions Cod::The Contractor's Liccnsc Law docs not apply to an owner of properly who builds or improves thereon.and who
<br /> does such work himself or through his own^mployecs,provided that such improvements arc not ind or offered for sale. If,however,the building or
<br /> improvement is sold within one year of completion,tate owner-builder will have the burden of proving that he did not build or improve for the purpose of
<br /> sale.)
<br /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the prsj=(Sec.7014,Business and Profession Code:The
<br /> Contractor's License Law does not apply to an owner of property who builds or improves thereon,and wlrnr,contracts for such projects with a contraclor(s)
<br /> licensed pursuant to the Contractor's License Law.)
<br /> ❑I am exempt under Sec. 73&P.C.for this reason
<br /> Date Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of iYorkers'Compensation Insurance,or a certified copy thereof(Sec.3$00.
<br /> Lab,C),
<br /> Exp.Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ACertified copy is filed with the County Building Inspection Division+.
<br /> CEWrIFICATE 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,1 shall not employ any person in any manner so as to become subject to the
<br /> Workers'Compensation Laws of California.
<br /> Date - Applicant
<br /> NOTICE TO APPLICANT:If,after making this Crrlificate of Exemption,you should become subject to the Workers'Compensation provisions of the
<br /> Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I herebyaffirm that there is a construction lending agency for the performance of the work for which this perrnit is issued(Sec.3097,Civ.C)_
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> ❑1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make iti connection with work
<br /> authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet
<br /> high. (Chap.3.2,Grp 2,A:t 2,Sec 341,Title 8,C.A.C.).
<br /> ❑As owner-buildcr,i will not employ anyone to do work which would require a permit from the Division of Industrial Safely,as no!ed above,unless such
<br /> person has a permit to do such work from the division.
<br /> D Division of Industrial Permit No.
<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 ordinances and state laws
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-nientioned
<br /> property tar inspection purposes.
<br /> Date_ Applicant
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