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J(a ADDnEss: 3' OC) �40C$J)f 17YMZ-"� cam} PEMIr 0: _ LICENSED CONTRACTORS DECLARATION I hereby alfrm that I am licensed under to provisions d Chapter 9 (comiTtencing with Section 7000) d DKision 3 of the Boniness and Pronasions Code and my krtee Is In full force and efoect. Llcetmse til �5 i l d U Z q Expiration Date -7 - :3 1 Data 1 Q l Contractor OWNER -BUILDER DECLARATION I hereby afMrn Meat I am exempt from the Contactors Lkww Law for the foliowing reason (Section 7031.5. Business and Protessbns Code. Any city or county which requires a permit to oonsbuuct alter. inprovs, demolish, or repair any structure. prior to its issuance, Woo requires ria applicant for such pertMt to tri a signed statement that M is licensed pursuant Ic Itis provisions of the Contrador's License Law (Chapter 9 (cotmnrmcimp with Section 7000) of Division 3 d Ma Business and Professions Code) or that he la exempt mullion n and the basis for the alleged exemption. Any violation d Section 7031.5 by any applicant for a pemmll s u ifetts the applicant to a dos penalty d not more than Ave hundred dollars (5500)) ❑ 1, as owner of Ire property, or my ernp/oyees with wegss as their sole comperrabon, will do l e work, and tit structure is not !," or offered for sale (Section 7044, Business mid Pronasion Code The contractors License Law does not apply to an owner of property who builds or Improves rireon. and who does such work himself or tfxayh his own employees, provided that such improvements ars not Intended or offered for sale if, however, the bu&*Q or Improvement Is sold within one year of completion, the ownw4xAder will have the burden of proving that he did not bold or Improve for the purpose of sale.) ❑ I. as owner of Ie property. am exclusively conlreclimg with scarred contactors Io construct this project (Section 7044, Business and PralMeions Code (33PC) The Contactor'. License law does not apply to an ower of property who hods or Inpoves hereon, end who constructs for such projects with a conlrectotf s) licensed pursuant to Ie Contrsdor a Lkerne Lew.) ❑ i am exempt under Section . UPC for tats meson Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a cerMlcete of consent b self -inure or a csrtilcar of Workers' Compersation Insurance, or a OWWW copy Iwed (Section 3800. Labor r"11m) r Expiration Data 0 �q Compan,_ N tlfY �. ItAL TAI (H$t�w+s 0 Cartfled copy Is hereby furnished ❑ Certised copy Is feed wtri the Environmental H*W Department U CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE fTtmis AnWm Fred not bet TmIalad lift oamilt Isfor ars hundred dolare (3100)or masa) I ow* that In Ie performance of the work for Mid this pemmlt Is Issued. I shat not ermploy any person In any manner so as b become *A*d b the Workers' Compensation L.rws of CaWania. Date: _ AppMcart NOTICE TO APPLICANT: If, air Inking this CsrtMkale of Exemption, you WvM become subled Io the Workers' Coetpenea w provWons of the Labor Code, you moat forth wNh comply with such provisions or this permit shat be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affi n Iat these Is ■ consiucson lermdng agency for the performance of Ie work for which this penrwt is issued (Section 3097, CMI Cada) Lenders Nara _-- — -- - - —.- Lenders Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby tarWy Mat no excavation Iva (5) or nae net In depth limb which a person Is required to descend, wIll be made In Connection wlth worst nrlrorited by Ie pwrr#. and Mme no bulding Wxkjre, walk ding, falsework, or demost on or dismantlsmg t Bred, will be more them Imirty-aloe (38) iset high (Chapler 3.2, Croup 2. Article 2, Section 341, Title 8, CaWorNa AdmlMstratiw Code). ❑ Aa own 4xdder, I will not employ anyone lo do work whish would require a permit from the Division of Indusbtal So", as noted above, umMaas such person hoe a perrmlt to do such work from tie division. ❑ Division of I dustrtal Safety Permit k I oertify ria I how reed to appicabon and star Mme the above Ix«m.ron Is coo, I " lo comply wM ail city and county ordi►rmm and star laws relating to wait comsirudbn end or so we" system construction. and hereby authorize representatives of ries county to �7t* above-+rermtloned Property for Inspection pu rp— EM 41e2Oe7 LICENSED CONTRACTORS DECLARATION a."