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JOB ADDRESS:
<br />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
<br />Professions Code and my license is in full force and effect
<br />License# C -F % fExpiration Date—
<br />Date 37iTz Contractor 6, ---.$ {
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am 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, alter, 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 Contractor's
<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 civil penalty of not more than five hundred dollars ($500)):
<br />❑ I, as owner of the property, or my 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
<br />owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that
<br />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 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 and
<br />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 />❑ 1 am exempt under Section , B&PC for this reason
<br />Date:
<br />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 Insurance, or a certified copy
<br />thereof (Section 3800, Labor Code)l
<br />Expiration Date SS / 71 g- Company 3'0 4i, WC 0 3.1 5211. 0 C
<br />❑ Certified copy is hereby furnished
<br />CCertified 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 hurxlred dollars IS 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' 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 construction lending agency for the performance of the work for which this permit is issued (Section 3097,
<br />Civil Code)
<br />Lender's Name
<br />Lender's Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<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 />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 noted
<br />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 II city and county
<br />ordinances and state laws relating to well construction and or sewage system construction, nd I)rar* uthori rgpfesentatives of this
<br />county to enter upo% thea o/ve-mentioned property for inspection purposes. /
<br />Date (� �l� Applicant
<br />EHD 43-02.007 LICENSED CONTRACTORS DECLARATION
<br />6-26-09
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