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Jos ADDRESS: PERMiT 0 - LICENSED CONTRACTORS DECLARATION I hereby affirm that I am "need under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is In kuN force and effect License ik) trS7 - -7100 %9 11 Ex (ration Date 7- 3 Date 71(3 t Contractor Ki OWNER -BUILDER DECLARATION I hereby affirm Nut I am exempt from the Contractor's Lfconse Law for the kAowkmg reason (Section 7031.5, Business and Prolomwom Code Army city or county which requires a permit b construct, otter Improve, demolish, or repair any structure, prior to its issuance also required the applicant for such permM to file a signed statement that he is licensed pursuant to the provisiora of the Contractors Lloanaa Law (Chapter 9 (cof� wish Section 7000) of Division 3 of tla Bodine" and Pro4assio a Code) or that he is exempt hwefrom and the basis for the alleged exemption. Any vitiation of Section 7031.5 by any applicant for a permit urb)ects the spnicart to a civil psrWty of not more than five hundred dollars (SSW)). ❑ I, as owner of the property, or my employese with wages as their dole compensation. will do the work, and the structure is not Mended or offered for sale (Section 7044. Busk)ns and Pmfessbrs Code. The contractor's License law does not apply to an owner of property who builds or improves Carson, and who does such work hires" or thx h hie owm employees, provided that such fmprovertwts are not intended or offered for seta. If, however, tie building or improvement is sold within one year of compietion. the owner -builder will have the burtien of proving Ilii he did not build or improve for the purpose of sale.) ❑ I as owner of the property, am excdusihh rely contracting with licensed contractors to construct the protect (Section 7044: Business and Profession Code (B&PC): The Contracbrs Licence Law does not apply to on owrw of property who builds or improved hereon.. and who constructs for such projects with a contracior(s) licensed pursuant lo the Contractors Licen" Law ) ❑ 1 am exempt under Section B&PC for this reason Date: Owner: WORKERS' COMPENSATION DECL ARATiON I Hereby affirm that I have a certrficate of consent to sett -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Labor Code) - Expiration Data /t7 ' % 7 Company 1AS120 ❑ Certified copy is hereby furnished P -Q -t: r_rtulwo copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This Section need not t Q completed if the permit is for One hundred dollars ($100) or less) I certify that in the performance of the work for which this permit Is issued, I shall not employ any person m any manner so as to become subject to the Workers' Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after makng this CerWkW* of Exemption, you should becorne subject to tta Worker' Cortpensation prvvisform of the Labor Code, you must torthwrth corrply with such provisions or thts pennit shaft be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued (Sealer 3097, Civil Code) Lender's Name Londer' Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person a required to descend. wA be made In conxacdon with work authorized by the pemr* and that no building structure. scaf"*V fabework or demolition or d4riw)( g thereof will be more than thirty-six (36) feet high (Chapter 3 2 Croup 2 Articie 2 Section 341 Title s California Administrative Code) ❑ As owner -builder. I will not ernpioy anyone to do wodc which would require a permit from the Dmsion of Industrial Safety, as noted above unless such person hes a permit to do such work from the division. ❑ Division of Industrial Safety Permit I certify that I taw read ttvs appllrcabon and stale that the above information is correct I agnea to comply with all city and cowty ordinances and state laws relating to well construction and or sew" system construction and hereby authorize representatives of this county to enter upon the above-mentioned property for Inspection purposes. Date Applicant EHC 43,07 L)CF.NSED CONTRACTOR DECLARATION toe=7