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3oB 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 /> G ( " U
<br /> License# o Expiration Date
<br /> Date0-3 Contractor D � - 'O ..A 1 --tS R111e✓
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 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 pepnit 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 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 I 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 ,r) Company 31ATIE Fvtrb
<br /> ❑Certified copy is hereby fiunished
<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 fot 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
<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 /> WI 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-huilder, 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 4
<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_F&f 3JZ ApplicantDA
<br /> EHD 43-02-007 MASTER Water Well Permit Contractor Dectaraction
<br /> 1215J21)t12
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