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JOBDDR..: I� 10 "r' C. hC.. RCA PERMITM
<br /> ,l
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of h 'pte 9 Co
<br /> Lmmenci with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license
<br /> isisrinn full force an e
<br /> License If . V/ a v O
<br /> Date Contra or
<br /> O R-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 Professions
<br /> Code: Any city or county which requires a permit to Construct,alter,improve,demolish,or repair any structure, prior to its issuance,
<br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors
<br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars($500)):
<br /> 0 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 Contractors License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> Completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ,SLI,as owner of the property,am exclusively contracting with licensed Contractors to Construct the project(Section 7044,Business and
<br /> 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 Contractors License Law.)
<br /> 0 lam exempt under Section , B&PC for this reason
<br /> Date: V—) 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
<br /> certified copy thereof( ection 3800,Labor Code).
<br /> Expiration Data 0 1 Company
<br /> 0 Certified Copy is hereby furnished
<br /> Certified copy is fled with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the Permit is for one hundred dollars(8100)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
<br /> as to become subject to lh,Workers'Compensation Laws of lifomia.
<br /> Date: Applicant �
<br /> NOTICE TO APPLICANT: If, after making this Certificate of fkamption,you should become subject to the Workers'Compensation
<br /> 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
<br /> (Section 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> b6hereby 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,Tide 8,California Administrative
<br /> Code).
<br /> 0 As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> 0 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 presentatives of this
<br /> County to enter upon the pabove-me tinned proper for inspection purposes.
<br /> Date 1 Z�P I, Applicant
<br /> EHD 4347 LICENSED CONTRACTOR DECLARATION
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