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JOB ADDRESS: e7i© L LJ �iIA4 CA PERMIT LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (comrnenckV with Section 7000) of Division 3 of tie Business and Profsssxxw Code and my license is in full force and effect License 0 t�S 7- 7/b675 pi tion ate -7,31,117 Date 71fA 111 Contractor Dnllu. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors Lkense Law for the kAowkmg reason (Section 7031.5, Business and Professions Code Any city or county which requires a permit to constrict, after. improve, dernoiish, or repair any structure, prior to its Issuance. also requires the applicant For such permit to So a signed stahsmenf that he is Ikersed pursuant to the provisions of the Contrwiors Llcersa Law (Chapter 9 (commrrwxx g with Section 7000) of Division 3 of the Bu ti esu and Professions Code) or that he Is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by army applicant for a permit subjects the appicant to a croft penalty of not more then five hundred dollars (5500)). ❑ I, as owner of the property. or my srnpioyses with wages as their some compensation. will do dw work, and ill structixe is riot intended or offered kr sale (Section 7044. Business and Professions Code The contracbra License taw does not apply to an owner of property who builds or knprows thereon, and who dose such work hineelf or through his own employees, provided that such knprovenents we not intended or offered for saie. H, however, the buNdk-g or knprwsnent is sold within one yeas of cornpietion, the owner-buMdef will have the burden of proving that he did not build or knfxwe for Its purpose of sale.; ❑ 1 as owner of its property, am exckxnveiy con&adxV wrth licensed contraclors to construct this project (Section 7044, Business and Professions Code (BSPC) The Contraclor's Lk»nse Law does not apply, to an ownef of property who builds or knproves hereon. and who Constructs for such projects with a contraclof(s) licensed pursuant to iris Contractor's License Law ) Cl I am exempt under Section , BLPC 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 ra Pt1ed copy thereof (Section 3800, Labor Code). Ex pi ration Date f7' /*00/i Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATK)N INSURANCE (This section need not be cornoleted if the permit Is for one hundred doltare (5 100) or iess) certrfy that in the performance of the work for which this permit is issued, I shall not employ any person n any manner so as to become subject to the Workers' Compensation Lawn of Califoria Date: Applicant NOTICE TO APPLICANT; If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must horthwith compty with such provisions or this pem-A shell 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 (Sec4on 3097, Civil Code) Lender's Name Lender' Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ I hereby certify that no excavation Roe (5) or more feet on depth into which a person is required to descend w* be made in oornsction with work authorized by rte permit, and that no Wi&dwV stnx.tun scat idirV taiwwork or den#tgn or dwrw"kng thereof will to more than thirty-six (38) feet high. (Chapter 3 2, Group 2 Article 2, Section 341, Tib 8 California Administrative Code) ❑ As owner -builder, I will not employ anyone to do work which would require a perrrA from the Dmsron of Indrxtnal Safety as noted above uniws such person hes a permit to do such work from the dhetsion ❑ Drvean of kxk stn ami Safety Parma N certify that I have read this application and state that the above inkrmation is correct 1 agree to comply with ori city and county ordinoroes and state hon relating to well corstarbon and or sewage system constriction and hereby authorize representatives of this couxxy to enter upon the abovwmenbooed property For kspection purposes Date Applicant ENO 43-07 LICENSED CONTRACTOR DECLARATION 101507