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JOB ADDRESS: i LtCENSD CONTRACTORS DECLARATION I herelsy affirm that I am ficenseo under the Profess ons Code and my license is In full force vand effect isions of hapfer 5 fgonunencing with Section 7 License fl -S �� 000)/Of Division of the Business and Data (/ �(�%�„ - "Y� Expiration Date :C> r Contractor/tr —_��_r 1 hereby affirm that I am exempt from OWNER -BUILDER DECLARATION i — Code. Arty city Or county which requires a permit 10 conLirestruct law for the follow n reason also requires the applicant for such Permit io corrstrud, alter: improve. demolish. orSE ate any structure,smess and Professions L+cCnse Lav, (Chapter 9 qq permit to file a signed statement brat he Is licensed pursuant to the r� to its issuance, ( mmencing with Section 7000) of Division 3 of the Business and Prntessans Code) or that he is exempt herefrOm and the basis for the alleged exemption..4ny violation o/ Section Provisions of the Contractor s to a ci -nasty of not more than live hundred dolla,s ($500)) 703t.5 4Y any aPfNioant for a permit subjects the applicant i as avmer of the property, o! my emptq;,ees rnih wages as their sole cam n intended or offered for sate (Section 7044 Business and Professions C owner of ro er 5a0oq ct do the work, and the structure is not P P Ty who builds or improves Ihermrn. and who Code the contractors License (.aw does not a such NnPrOver itnts are not intended or offere,! tar does such work himself or through his own employees, apply to an comPlelion the owner -builder will have the burdEn of proving If however, me building W Yeea, p ovlded that ghat he did not buikt or i g improve improvement is sold with one year of O I, as owner of ilii property, am exclusively conlrarbrt n nrgve for !h0 purpose of sate.) Professions Code (BgPC) The, vnih kcen•1 contractors IO construct the r and who Constn,cts for such CoConlractOr's License law does rmt a project (Sectron 7Qa4 projects with a ^onlraclor(5} licensed pur5vam [o he CO iraCfOrS��n cro builds or i ' awesRusegs and 1 am exempt under Section mproves hereon. 5 B8 PC for thisreason _ i Date: —~� e•_ :"t t C 1� 'Rt.t^i WORKERS' COMPENSATION DECLARATION' 1 hereby affirm that 1 have a certificate of consen! to �-ell.insure or a Certificate of 4VOrkerS mppnsah0 thereof (Section 3600. ) Ni95ura Expiration Date or a certified copy I a 0 Ce ed copy rs her Company C"_� J _ �✓ � co hereby furnished PY is filed with the environmental health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rhtis secho_i n_neevno� be—rr p!flfyt d Itle peermrt_ s tnr one hurt 1LrEd dollars (, l SLQ07 orIpcs1 i r:edity that m the performance of the work for wh;ch. this permd u issued, ,-crime subject to Ne V�torker5 Compensation laws of enmtiCalifornia, I shall not employ any Person in any manner so as to Date: --- - — --- Applicant NOTICE Tof APPLICANT: It, ager making the Cenifirate of Exemption you should become subject to the Workers' Compensation Provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY 1 herby alFrm that there is a Construction lending agency for the performance of the work for which this Civil Coee; Lender's Name Permit is issued (Section 3097 Lender's Address 13 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION I hereby certify that no excavation five (5) or '"Ore feet in depth into which a person is requned to de connection w+ih work authprrzed by the permd and that no building structure, scaffO o . to Code) wilt be more than thirty-six (36) feel h hemoliti descend wig txr made in Code! 9 !Chapter 3.2. Group 2 Article Z Section 3411oTilte (t,tC California or dismtr7ifive ❑ ab owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless strati person has a permit to do such work (fort, the division. ❑ Division of tnnustrial Safety Permit # _ ll' "OP t divan Hiatt have read This ting jeaban and state that the above information is cxrect. (agree to comply With all city and county ordinances and state taws rglating !o well consbuctiar and or sewage systern COnslruction, aI hereby authorize representatives of this cpurny to enter upon the above ro Date p pert! for 11SPection purposes. - -- — Applicant - CMO 45.02.007 6-28-o!) f UCENSEO CONTRACTORS DECiARAT70N