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1' <br /> JOB ADDRESS: PERMIT#: <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 Professions Code and my license is in full force and effect, <br /> License#� e Expiration Date <br /> Date 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 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 herefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects <br /> the applicant to a civil penalty of not more than five hundred dollars <br /> 111, 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 /> ❑ 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 /> ❑ I am exempt under Section_ B&,PC for this reason <br /> Date: Owner <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that 1 have a certificate of consent to self-insure, or a certificate of Workers' Compensation Insurance,or a certified <br /> copy thereof(Section 3800, Labor Code). <br /> Expiration Date Company <br /> ❑ Certified copy is hereby furnished <br /> ❑ Certified copy is filed with the Environmental Health Department <br /> CER'T'IFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be coiripleted if the permit is for one hundred dollars(S 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 /> ❑ 1 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, Califomia 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 /> M to Applicant <br /> EHD 43-02-007 MASTER Water Well Permit Contractor Declaraction <br /> 5/28/2002 <br />