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JOB ADDRESS: / Q O �• �L '1 u 1-7 LI--- PERMIT #1:
<br />LICE 4SED CONTRACTORS DECLARATION
<br />1 hereby affirm that I am licensed under the pro-, sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
<br />Professions Code and my license is in full force ind effect.
<br />License*_ 96 8 Z Expiration Date
<br />Date / / — Z 7—" / �—, Conti 14e-4—
<br />)WNER-BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contr ictor's License Law for the following reason (Section 7031.5, Business and Professions
<br />Code: Any city or county which requires a pe nit to construct, alter, improve, demolish, or repair any structure, prior to its issuance,
<br />also requires the applicant for such permit to f a a signed statement that he is licensed pursuant to the provisions of the Contractor's
<br />License Law (Chapter 9 (commencing with Se .tion 7000) of Division 3 of the Business and Professions Code) or that he is exempt
<br />herefrom and the basis for the alleged exempt n. 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 - ollars ($500)):
<br />0 I, as owner of the property, or my employ( as 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 t Iereon, and who does such work himself or through his own employees, provided that
<br />such improvements are not intended or o fered for sale. If, however, the building or improvement is sold within one year of
<br />completion, the owner -builder will have the I urden of proving that he did not build or improve for the purpose of sale.)
<br />13 1, as owner of the property, am exclusively c ntracting with licensed contractors to construct the project (Section 7044, Business and
<br />Professions Code (B&PC): The Contractor ; License Law does not apply to an owner of property who builds or improves hereon,
<br />and who constructs for such projects with a Ontractor(s) licensed pursuant to the Contractor's License Law.)
<br />Ci 1 am exempt under Section B&PC for this reason
<br />Date- C tuner:
<br />WOR (ERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of c )nsent to self -insure or a certificate of Workers' Compensation Insurance, or a
<br />certified copy thereof (Section 3800, Labo Code).
<br />Expiration Date 1-1-17 L :Impany
<br />f—� a
<br />❑ Certified copy is hereby furnished
<br />IX Certified copy is filed with the Environrr ,ntal Health Department
<br />CERTIFICATE OF EXE dPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This section need not be completed if the permit is for one hundred dollars (SI 00) or tess)
<br />I certify that in the performance of the war 'for which this permit is issued, I shalt not employ any person in any manner so
<br />as to become subject to the Workers' Cor pensation Laws of California.
<br />Date:
<br />NOTICE TO APPLICANT: If, after making th s Certificate of E=xemption, you should become subject to the Workers' Compensation
<br />provisions of the Labor Code, you must forthw h comply with such provisions or this permit shall be deemed revoked.
<br />,ONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there is a construction tending 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 (` ) or more feet in depth into which a person is required to descend, will be made in
<br />connection with work authorized by the p, rmit, and that no building structure, scaffolding, falsework, or demolition or dismantling
<br />thereof, will be more than thirty-six (36) fe >_t high. (Chapter 3.2, Group 2, Article 2, Section 341, Title S, California Administrative
<br />Code).
<br />L3 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 tc do such work from the division.
<br />Q Division of Industrial Safety Permit #
<br />I certify that i have read this application an( state that the above information is correct. I agree to comply with all city and county
<br />ordinances and state laws relating to well con ,truction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon the above-mentioned pr, party for inspection purposes.
<br />Date
<br />EHD m3-07
<br />1015107
<br />Applicant
<br />L'CENSED CONTRACTOR DECLARATION
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