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<br /> JOB AADRESS: PERMIT#:
<br /> 51
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Di sion'3 of 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 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($500)):
<br /> ❑ I, as owner of theroe `
<br /> p p rty; or my employees with wages as their sole compensation, will do the work, and the structure is nott
<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 /> f 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 /> ❑ 1, 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 /> ilk
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I hereb affirm that I have a certificate of consent to self-insure,or a certificate of Workers' Compensation Insurance,or a certified
<br /> op (RiM
<br /> ix a
<br /> ❑ rtified co - iT,
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> ti
<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 /> 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 <; i
<br /> NOTICE TO APPLICANT: If, after making-4his-ZCertificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Lalbor 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 /> �— ❑ 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# f
<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 12/23/2003
<br /> Water Well Permit Contractor Declaraction 4-02
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