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09/25/2017 06:10 FAX 4156427055 CANON
<br />JOB ADDRESS:_G, �` }i 7,' %cis So/\ 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 # 1 f Expiration Date
<br />Date9 .2 �_ Cohttactor Sr11
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that 1 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 I aw (ChTnler 9 (rnmroenrJn0_vitb SArtioo 7=)1 of Divlsinri—a of the Rllsinfws anrlprefAscions Cnda) nr that he is Axf-mriL
<br />herefrom and the basis for the alleged exemption. Anv violation of Section 7031.5 by anv aoolicant for a oermit subiects the aonlicant
<br />to a civil penalty of not more than five hundred dollars ($500)):
<br />13 I, no owner of the pmperty, or my employees with wegea ea their pole oompenootion, will do tho wort, end the stn t.— io nut
<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 wFr0vAdr.rsr•. -4 ,.d.n A— -,t, :.....L l i �olc ar lhrr, rb, h , r��.Pc^PIav4RF, { ry a +sd k4a;
<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 />Cl 1, as owner of the property, am exclusively contracting with licensed contraclom to construct the project (section 7044, DvOnea6 and
<br />Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds of Improves hereon,
<br />e..a ..l.e --41-4. fo, pooh p—).� 4th a oo t aoe9r(ol uoo....d P-. ,t ro the ce t.e etc +e upon., L.—)
<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
<br />certified copy thereof (Section 3800, Labor Code).
<br />Expiration Date Cornipany
<br />Certified copy is hereby furnished
<br />R CArtifiarl nnpy i� filar( with the Fnvirnnmantal Health i i ortnrlmant
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This section need n t be completed if the Rernlit is for one hundred dollars ($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
<br />as to 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 />0—iaiv ..f tl,o Ld.u, O -du y..0 ,,,uet F.., thwitl, -.ply with ou..h p. inlo,io or IN. pam.it i-11 t.., cico„,�J ,pv4t�J.
<br />CONSTRUCTION LENDING AGENCY
<br />hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
<br />(Gcdian 0007, Civil O.d.).
<br />Lendees Name
<br />Lender' Address _
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />XI hgnahy �nity mit ne eXoavatlon nve (5) or more 116,9 In Qepm Inco Wnion ^„ peroon :o roqulroa re 90^00n^ "-" -- M.
<br />GUIIIit!UdUrl Willi wUlk dUV1UIILea uy inu pefnlll, allU llldl nu
<br />CIO UUIIUIIIg JuGrUre, SGaffulUing, rdl5ewunt. ur ae nollilon or alsmanilmg
<br />thereof, will be more than thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, Califomia 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 />n 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 with all city and county
<br />ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of
<br />�this
<br />courtly to enter up n the ab v�e--mentioned property for inspection purposes.
<br />Date -2 / _ Applicant
<br />EHD 43-07 LICENSED CONTRACTOR DECLARATION
<br />70/5!07
<br />Received Time—Sep, 25.-2011— 6:20PM—No, 235
<br />10003/007
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