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AA Joe ADDRESS: IPIV ZV• 5+1+�,Ph Zehl r -?5A/2 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. Licertse # c/Now Expiration Date Date //- Ira -/> Contractor &Z 461t" f S2NS A,m 92 Sit v r c Ir OWNER -BUILDER DECLARATION I hereby d5 n #r d I am exempt Ion the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to consbud. atter, hnprove, demolish, or -par any structure. prior to its issua nca, also requires the applicant for such permit to fie a signed statemerit that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commericm with Sermon 7000) of Division 3 of the Bwmxss and Professions Cade) or that he is exempt hamfron and the basis for the alleged enemplion. Any violation of Section 7031 S by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)y p I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not ahtended or offered for sale (Section 7044, Business and Pmfessions Code: The contractor's License Law does not apply to an owner of property who builds or improves tthemon, and who does such wok himself or 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 carrion, the owner4xnkler will have the burden of proving that he did not build or improve for the purpose of sale.) 13 4 as owner of the property, am exciusvely contracting with licensed contractors to construct the project (Section 7044. Businew and Professions Code M&PC): The Contractor's License Law does not apply to an owner of properly who builds or Improves hereon, and who constructs for such projects with a contractor(s) licensed pursuant to the Contractors License Law.) 13 1 am exempt under Section , B&PC for this reason Date: Owner: WORKERS' COMPENSATION DECLARATION I hereby of in, that I have a cetift .rate of consent to selfinsure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Labor Code). Expiration Date Company 0 Certified copy Is hereby fumished 0 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section meed not be completed if the Dem it Is for one hundred dollars ($100) or less) I certify that in the performance of the work for which this permit is issued. 1 shall not employ any lin in any manner so as to become subject to the Workers' Compensation Laws of Cafifomia. Date: //L SO-/$ Applicant T ldW NOTICE TO APPLICANT: If, afiar making this Certificate of you shoo subject to the Wafters' Compensation provisions of the Labor Code. you mud forthwith comply with such provisions or this percent shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lenders Name Lender' Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 1 hereby aer6y flat rico excavation five (5) or more feet in depth Alto which a person is required to descend, will be made in connection with work authorized by the permit, and that no building structure. swRoidirrg, falsework, or donofitim or dismantling thereof. wit be more Om thidy-sit (36) fed high. (Chapter 32, Group Z Article Z Section 341, Tile 8. Cafdomia Administrative Code). 0 As owner-buider, i will not employ anyone to do work which would require a permit fiom the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division_ O Division of lydustriai Safety Peamit # I certify that I have read this application and state that the above inthr matim M correct. I agree to comply with all city and county ordinances and state laws reiatahg to well duction and or sewage system consbuction, and hereby authorize representatives of this cosily to eater upon the above-rrerntioned property for inspection purposes. Date EM4347 110607 Applicant LICENSED CONTRACTOR DECLARATION