|
JOB ADI?REss: PERMIT#:
<br /> ^ i
<br /> LICENSED CONTRACTORS DECLARATION ,
<br /> I hereby affiim that Ilam 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. '' \z + 1
<br /> License# ` \. \ 4 . w ' Expiration Date 1
<br /> Date ' ,\°� ..� \ Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that'.I am exempt fiom,the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or,county:which requires.�a'pemrit 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 Proessions Code)or that he
<br /> 4 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 /> ❑ 1, as owner of the-property,'orrriiy 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 co letion,
<br /> mp , , g � Y -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 /> r ❑I am exempt under Section B&PC for this reason
<br /> }
<br /> Date: Owner
<br /> r
<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 /> p erea (S r 0,Ms
<br /> XP
<br /> x a omp y
<br /> ❑ o is her LMM
<br /> C3 Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> This section need not be co leted 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_
<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 /> r
<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 /> r 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#
<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
<br />
|