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<br /> Jos ADDRESS: f y I ,r! j 1 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 and Professions Cade and my license is
<br /> in full force and effect. Q
<br /> License " �1 ExppirjatiionDate V13 S_ .J
<br /> Date i z 6 3 Contractor��t/^ /�ir� r`Da4*h a, v�"Aes
<br /> 'FO? Sle t t�, A� ,
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby air=that I am exempt from the Contractor's license Law for the following reason(Section 7031.5,Business and Professions Cade: Any city or county which
<br /> requires a permit to construct,alter,improve,demolish,or repair any stmettue,}rice to its issuance,also requires the applicant for such permit to file a signed statement that
<br /> he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(eormnencing with Section 7000)of Division 3 of the Business and Professions Code)
<br /> or that he is exempt herefrom and the basis far the alleged exemption Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
<br /> of not more than five hundred dollars($500)):
<br /> O 1,as owner of the property,or my employees with wages as their sole cornpensation,will do the work,and the structure is not intended or offered for sale(Section 7044,
<br /> Business and Professions Code:The contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or
<br /> through his own employees,provided that 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 ofpraving that he did not build orimprove fm the purpose of sole.)
<br /> ❑1,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,and
<br /> 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 Imurance,or a certified copy thereof(Section 3800,Labor
<br /> 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 for one hundreddollars($100)or less)
<br /> I certify that in the performance of the work for which this pemdtis issued,I shall not employ anyperson in any manner so as to become subject to the Workers,
<br /> 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'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 constructionlending agency for the perforruanee of the work forwhieh this pan-nit is issued(Section 3097,Civil Cade).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> O 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 connection with work authorized by the
<br /> permit,and that no building structure,scafFolding,falsework,or demolition or disnanrtling thereof will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article
<br /> 2,Section 341,Title 8,Caliknup Administrative 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 /> ❑Division of Industrial Safety Permit it
<br /> I certify that I have read ibis application and date that the above htrormation is correct.I agree to comply with all city and county ordinances and state laws
<br /> relating to well construction and or sewage system Construction,and hereby authorize representatives of this county to enter upon the above-mentioned property
<br /> for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 LicensM Contractors Declantion.doc
<br /> 8120/2003
<br /> :'700a� b
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