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JOB ADDRESS: ZI4 5 W Ravhw loa, UL PERMIT#:
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of
<br />Professions Co �p se Is in full force and effect.;
<br />License ULA II J pig,
<br />jj/ ion Date
<br />Date Contractor � ,.1. VDIII I YI A I l 1v
<br />y
<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 />E3 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 />0 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 />0 1 am exempt under Section , B&PC for this reason
<br />Date:
<br />Owner:
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I haveCertificate of consent to se f-insur or a ificate of orkers' Compensation Insurance, or a
<br />certified copy thereof Se 3 0, Labor Code).
<br />Expiration Date Company
<br />0 certified copy is he eby rnished
<br />Certified 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 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:
<br />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
<br />(Section 3097, Civil Code).
<br />Lender's Name
<br />Lender' Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />O 1 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 />O As owner -builder, I will not employ anyone to do work which would require a permit from the
<br />above, unless such person has a permit to do such work from the division.
<br />0 Division of Industrial Safety Permit #
<br />I certify that I have read this application and state that the above information is correct. I ato
<br />ordinances an stat laws relating to well construction and or sewage system ns ctio , an h by
<br />county to ente upol th ove-mentioned property for inspection purposes.
<br />Date Applicant
<br />EHD 4307
<br />10/5/07
<br />of Industrial Safety, as noted
<br />reply with all city an county
<br />thor�ze representati s of this
<br />LICENSED CONTRACTOR DECLARATION
<br />
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