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JOBADDBEss: SODD SD. A;rRgfA WAI� PERk11T#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby argon that 1 am licensed untler the provisions of Chapter 9(commencing with Section 7000)of Division 3 of Me Business and
<br /> Professions Code and my license is In NII force and affect.
<br /> License# e1 D.9,216 — CIA-, A ,I Expiration Date
<br /> Data IJ2d/j2 Contractor CpTAcf/i�ovlf lzaf-wlP�
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby of on that I son 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,atter,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 ovil penalty of not more Man five hundred dollars($500)):
<br /> O I, as owner of the property,or my employees with wages as Meir sole compensation, will de the work,and the structure is not
<br /> intended or offered for cab(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 Mat
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> mmlplation,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> O I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Cade(BaPC). The Contractors Ucei Law does not apply to an owner of property who bugds or improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractors License Law.)
<br /> O 1 am exempt under Section , BBPC for this reason
<br /> De": Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure or a certificate of Wodrers'Compensation insurance,or a
<br /> certified Copy thereof(Section 3800,Labor Code). G
<br /> Expiration Date Ili 2 Company FtfLA'J!A IS 1 N✓1
<br /> �ertified Copy is hereby furnished
<br /> Cl Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not tie completed if the permit Is for one hundred dollars($100)or le
<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 the WorkersCompensation 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 forltrdth comply with such provisions or this permit shag 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 Ifsl
<br /> erCode)gift
<br /> 'w
<br /> Lender's Name Ig
<br /> Lendee Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> �ereby 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,falsewvrk,or demolition or dismantling
<br /> thereof,will be more than thirty-fit(36)feel high.(Chapter 3.2.Group 2,Article 2,Section 341,Tine 9,California Administrative
<br /> Code).
<br /> O As owner-builder,I will not employ anyone 10 do work which would require a permit from the DMsion of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> 13 Division of Industrial Safety Permit It
<br /> I certify that I have read this application and alete that the above information is correct. I aur���.(r mc1TpT'Or II city and county
<br /> ordinances and state laws relating to well construction and or sewage system con grc'on dTiere authoriyg.f n y and
<br /> of this
<br /> county to enter upon Me above-mentioned property for inspection purposes,
<br /> Date i 2sj! 11- Applicant
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