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SOB ADDRFss, PERMIT 9.-
<br /> LICENSED
<br /> :LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divisfori 3-off the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License#_ Expiration Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I arra exempt from the Contractor's License Law for the following reason (Sedion 7031.5, Business and
<br /> Professions Code: Any city or cotuity which requires a permit to construct, alter, improve, demolish, or repair any strucit re,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($500)):
<br /> ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contacting with licensed contractors to construct the project(Section 7044, Business
<br /> and Professions Code(B&PC); The Contractor's License Law does not apply to an owrier of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law,)
<br /> ❑I am exempt under Section B&PC for this reason _
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a cei-tif cate of Workers' Compensation Insurance,or a certified'-"'
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑ Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is foi one hundred dollars '$ or lest
<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 /> Leader' 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, 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 -,rnrl[,tar:'_ka c:ivision.
<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 /> Date 'Applicant
<br /> EHD 43-02-007 MASTER Water Well Permit Contractor Declaraction
<br /> 5/2 W002
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