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Jul. 13. 2017 10:33AM Canepa & Sons No, 9007 P. 3
<br />Joe ADDRESS; N' � PERM
<br />Joe
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that I em licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bualness And
<br />Professions Code and my license Is In full force and effect.
<br />License # 425749
<br />Expiration Date 7/31/18
<br />Date Contractor CANEPA AND SONS, INC,
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 .9, Business and Professions
<br />Code: Any city or county which requires a permit to conatruct, 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 />❑ 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 Bale (Section 7044, Business and Professions Code: The contractor's License Lew does not apply to an
<br />owner or 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 />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Secllon 7044, Business and
<br />Professions Code (BRPC): The Conlractor'B 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 />❑ I am exempt under Section , BBPC for this reason
<br />Date: 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 />cerllfied copy thereof (Secllon 3800, Labor Code).
<br />Expiration Data 7/16/1-7 Company AU INSURANCE SERVICEs
<br />0 Cerlifled copy is hereby furnished
<br />0 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 Ih - 2Qrmit is for one hundreddollars ($100) or leaaAl
<br />I certify (hat 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 Callforole,
<br />Dane_
<br />Applicant
<br />NOTICE TO APPLICANT: If, eller making this Cenlrlcale of Exemption, you should become subject to the Workers' Compensation
<br />provisions of the Labor Code, you must forthwith comply with such provisions of this permit shell be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there i8 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 />❑ 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 w11h work authorized .by the permit, and that no building structure, scaffolding, ralsework. or demolition or dismantling
<br />Ihereof, will be more than thirty-six (36) feet nigh, (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br />Code).
<br />❑ As owner -builder, I will not employ anyone to do work which would require a permit from the OIvision of Industrial Safely, as noted
<br />above, unless such person has a permit to do such work from the division.
<br />❑ Division of Industrial Safety Permit#
<br />I certify that I have read this applicatlon and slate that the above information is correct. I agree to comply with all city and county
<br />ordinances and slate laws relating to well construction And or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon the above-mentioned properly for inspection purposes.
<br />Date
<br />ERO 4307
<br />10/5107
<br />Received Time Ju1,13, 2017 10:44AM No,1877
<br />Applicant
<br />LICENSED CONTRACTOR DECLARATION
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