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JOB ADDRESS: PERMIT #: LICENSED CONTRACTORS DECLARATION i nereby affimt that 1 am licensed wider the provisions a Chapter 9 (commencing with Soction 7000) of Dms�on 3 of the Business and Professions Code and my ikense is in full force and O feet. License 0 t 14 s Expintfon Date LET o zziC 1 Date t! / 'Z 0 / ZUf b Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sector• 7031.5. Business and Professions Cade Any city or county which requires a permit to construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant fcr such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Secttor 7000) of Divnsien 3 of the Business and Professions Code) or that he is exempt nerefrom and the oasis for the alleged exemptoon. Any v6abon of Section 7031.5 by any applicant for a permit subjects the applicant to a evil penalty of not more than, five hundred dollars ($500)J: ❑ i- as owner of the property or my employees with wages as their sde compensation, will do the work and the structure is not intended or offered for sale (Section 7044 Business and Professions Code: The contractors License Law does not apply to an owref of property who bu�lcs or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. if however, the building or improvement is sold within one year of completion, the owner -budder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ t, as owner of the property. am exclusively contracting with licensed contractors to construct the protect tSection ?044. Business and Processions Code (BEPC): The Contractor's Lcense Law does not apply to an owner of property who builds cr improves hereor., and who CahslrUCiS for SUCK protects mth a Contractors) licensed pursuant to the Contractor's License Law.; ❑ 1 am exempt under Section _______ _.. __ BSPC for th s reason Date: Owner WORKERS' COMPENSATION DECLARATION I nereby affirm that I have a certificate of consent to sett -insure or a certificate of Workers' Compensat= Insurance, ar s certKied copy thereof (Section 3800. Labor Code) - Expiration Date Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be compleleC if V -e Qermit s far me h mired dollars (51WI or less1 1 certify that in the performance of the wont for which this permit s issued. I shall not employ any person in any manner so as to become subject to the 'rVorkers Compensation Laws of California. Date: Applicant—__ NOTICE TO APPLICANT If, atter making trh!s CaMriicate of Exemption, you should became subject to the Workers Compensation provisions of the Labor Code, you must farthvvith comply with such provisions or this permit "I be deemed revoked_ CONSTRUCTION LENDING AGENCY I nerecy affirm that there is a construction lending agency for the performance of the wdrk fcr which this permit is issued (Section 3087. Civil Coda) Lenders Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be made ;n connection with work authorized by the permit, and that no budding structure, scaffolding, falsework, or demolition or draman9ing thereof, will be more than thirty-six (36) feet rvgh. (Chapter 32. Group 2, Article 2. Section 341. Title 8. California Administrative Code) ❑ As owner -builder. I will not employ anyone to do wont which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the d vision. ❑ Division of Industrial Safety Permit+ 1 certify that I have rear this application and state that the above information is correct. I agree to t:OmPiy w4h ail city and county crdlnances and State laws relabng to well construction and or sewage system construction. and hereby authonze representatives of this county to enter upon ine stove-ment oned property for inspection purposes Date Applicant EIaD �3•C1.007 _iCENSED CONTRAG0115 bECLkRATiON aaaw