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, APR/1.9/2017/WED 02:46 Plq FAX No, P.003
<br />JOB ADDRESS: r"" PFRMIT #:
<br />--IA���� .
<br />I hereby affirm that I am_
<br />Profesalons cd aTf�tp
<br />License # iV1 .
<br />LICENSED CONTRACTORS DECLARATION
<br />unde the provisions of Chapter 9 (comfnoncing with Section 7000) of
<br />fHtill force and affect
<br />_ ,/e ) (-Txplration Date J--
<br />gate LA I I /� t 11` Contractor ; /,1'L
<br />OWNER -BUILDER DECLARATION "
<br />3 ofth4 Bualne�A and
<br />I hereby affirm that I am exempt from the Corroaat r 5 Lleense Lew for the following reason (Section 7031.5, Bualnesa 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 requirea the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractors
<br />License Law (Chapter a (oommanclnd with Sc*tion 7000) of Divlelon 3 of the Business end Profeeslona Code) or thzt he is exempt
<br />herafrom and the basis for the Alleged exemption. Any vlolatlon of Section 70315 by any applicant for B permit subject; the appflcant
<br />to a oMf penalty of not more then five hundred dollars ($500)):
<br />d I, as owner of the property, or my employees with wagee as their Bore cornpenzatlon, will do the work, and the stucture Is not
<br />intended or offered for sale (Sectlon 7044, Buslnaes and Profa„slons Code: The contractor's License Law does not apply %:, an
<br />owner of property who builds or Improves thereon, end who does such work NmBelf or through his own employ®os, provided that
<br />ruoh improvements are not intended or offered for sale. It, however, the building or improvement Is sold within one year of
<br />completion, the owner-bullder will have the burden of proving that he did not build orimprove, forthe purpose of eale.)
<br />IJ I, as owner of the property, am excfualvely contraoting YAth Ilcensed eohtrectors to conetruct the project (Section 7044, Buslness 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 censtructs for Such projeotJ with o oontraotorfs) licensed pursuant to the Corxractor'a Llcenae Law.)
<br />❑ I em exernpt under Secton B&PC for thin reason
<br />Date;
<br />Owner:
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I haV a Certificate of consent to self- Asu or a certlfica .q of Workere' Co penaation Insurance, or a
<br />certified copy thereo�(S ct{on 38 bor code), ;
<br />Expiration Date �. Company 7L
<br />b Ce #td copy is here y furnished
<br />ertlfled copy Is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />f Thia section need not be completed If the permit Is for hulfLd g2Lg ($1001 or less)
<br />I certify that In theperformance of the work for which this permit is issued, I shall not employ any person in any manner Bo
<br />as to become eubject to the Workers' Compensation Laws of California.
<br />Date: Applicant
<br />NOTICE TO APPLICANT: If, after making thla CoMfioate of Exemption, you should become subject to rile Workers Compensation
<br />provlalona of the Labor Code, you must forthwith comply with such provisions or this permit shall bo deemed rovokod.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there Is a constructlon 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 />LA 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 bulfding structure, scaffolding, falsework, or demolition or dismantling
<br />thereof, will be more than thirty-slx (36) feet high. (Chapter 3.2, Group 2, Article 2, Sootion 341, Title 8, California Administrative
<br />Code).
<br />❑ As owner -builder, I will not employ anyone to do worK which would require a permft from the Division of Industrial Safety, as noted
<br />above, unless Buch person hoe a permltte do such wotk from the divislon.
<br />❑ DNlsion of Industrial Safety Permit fl
<br />I certify that I have read this application and State that the above information ie cot I agree to mply with II city and county
<br />ordinances an atate lff.v
<br />eI-dog to well construction and or sewage system co t ion, a by uthorize rep as f a of this-
<br />courtly to upon �m tioned property for inspection purposae. ff /
<br />Date Applicen f lam'. G�
<br />EHD 43.07 LICENSED COMRACTOR DECLARAYION
<br />t a6mr
<br />Received Time Apr,19. 2017 2:48PM No,1284
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