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Joa ADDRESS: 3 -(/S-,2 (^O ♦` L��CQ fC l� �CAMLO C/ r7.Z� PERMIT # LICENSED CONTRACTORS DECLARATION 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 Code and my license is in full force and effect ucense # 9NGW Expiration Date -3/ -/6 Date 3-i7 Contractor 46WJ* A&4JS A+ ip SErut F OWNER -BUILDER DECLARATION tI hereby affirm that 1 am exempt from the Contractors License Law for the following reason (Section 7031.5, Business and Professions - r Any city or county which requires a permit m construct alter. improve, demolish, or repair any structure, prior to its issuance, req the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) Or that he is exempt herefrorn and the basis for the alleged exemption. Any viotalion of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)); 13 1, as owner of the property, or my employees with wages as their sole con e intended or offered for sale Pen, will do the work, and the structure is not (Section 7044, Business and Professlors Code: The contractors License Law does not apply 10 an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sate. ff however, the or i completion, the owner -builder will have the burden of build or improve rhor the purpose is sold within one year of proving that the did not bra -Id or improve for the purpose of sale-) 13 I. as owner of the property, am exclusively contracting with licensed contractors to construct the project Professions Code (BbPC): The Contractors License Law does not apply to an owner of (Section 7044. Business and and who constructs for such contractor(s) licensed who trued- or ire Protects with a contra pursuant 1n the Contnectors License Law.) P� hereon, O 1 am exempt under Section _, B&PC for this reason Date: Owner. WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Labor Code). Expiration Date Company O Certified copy is hereby furnished 0 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the oerrrtit is for one hundred dollars ($100) or less) 1 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 become subject to the Workers' Compensation Laws of California. Date:i -�-/> Applicant-� % A NOTICE TO APPLICANT; ff. after making this Certificate of Exemp , yen+ shoo subject 10 the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency fuer the performance of the work for which this permit is issued (Section 3097, Civil Code). Lenders Name Lender Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 1 hereby certify that no excavation two (5) or more feet in depth into which a pennon is required to descend, will be made in connection with work authorimd by the permit, and that no building structure. scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high- (Chapter 32, Group 2, Article 2, Section 341, Title 8, California Administrative Code). 0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial above, unless such person has a permit to do such work from the division - Safety, as rented El Division of Industrial Safety Permit # I certify that 1 have read this application and state that the above information is cored I agree to comply with all ordinances and state laws relating to well construction and or sewage system construction and herebyauthorize representatives city and county county to enter upon the above-mentioned property for inspection purposes- Date urposes of this Date Applicant _ EM +9-07 1oisw LICEMED CONTRACTOR DEC ARpmoN