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<br /> JOB ADDRESS: , PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby affirm(hal I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Processions Code,
<br /> and my license A in full force and effect,
<br /> License# 5 �_ Exp_:Datc
<br /> Datcl� Contractor4.e_&W6LL-d2
<br /> OWNER-BUILDER DECLARATION
<br /> I ticrebv 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 a permit to construct,alter,improve,demolish,or repair any structure.prior to its issuance,also requires the applicant for such permit
<br /> to file a signed statement that he iz licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt hcrefrom and the basis for the alleged excmptiou, Any violation of Section 7031.5 by
<br /> any applicant Fara permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)):
<br /> C7 I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and[lie structure is not intended or offered for sale
<br /> (Sec.7044,Business and Professions Code;Tlie Contractor's License Law does not apply to an owner of propeily who builds or improves thereon.and who
<br /> does such work himself or through his awn employees,provided that such improvements are not intended or offered for sale. If,however,the building or
<br /> improvement is sold within one year ofcomplaion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of
<br /> sale.)
<br /> I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:The
<br /> Conuaaor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projce(s with a conlrarlur(s)
<br /> licensed pursuant to the Contractor's License Law.)
<br /> 0 1 am exempt under Sec. 13&P.C.for this reason
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<br /> i.71.
<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 Workers'Compensation Insurance,or a certified copy thereof(Sec.3800.
<br /> Lab.Q. f
<br /> Exp_D= Company" � Company 4
<br /> Certified copy is hereby furnished
<br /> Certified copy is filed with the County Building Inspection Division
<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 /> Icertify that in the performance of(lie work for which this prrmit is issued,1 shall not employ any person in any manner so as to become subject 10 the
<br /> V4rkers'Compensation Laws of Cal'tfemia.
<br /> Date Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workcrs'Compensation provisions of the
<br /> Labor Code,you must forthwith
<br /> tt 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(Sec.3097,Civ.Q.
<br /> Lcrider's Name
<br /> Lender's Addres
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION.-
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<br /> ERTIFICATION:0 I hereby certify lhaf no excavation five(5)or more feel in depth into which a person is required to descend,will be make in 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,Art 2,Sec 341,Title S,C.A.C_),
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safely,as noted above,unless such
<br /> person has a permit ir,do such work from Elie division_
<br /> ❑Division of lnd:rstrial 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 wCll Construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned
<br /> property for inspection purposes_
<br /> D;uc_ Appiicant
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