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4t I JAe ADDRESS: PERMT S: LICENSED CONTRACTORS DECLARATION I hereby affirm Bat I am licensed under ft provisions of Chapter 9 rcommwlcinq with Section 7000) of Division 3 of to Business and Professions Code and my b oanse to in fed force and eRea Llconso/ U 70 ' l Expiration Date �'✓ � � �� Date L 7 O/ f Pi Contractor ��v �D (tet?. �� rt OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lew for the fofaMnp reason {Section 7031.5; Business and P: cfassrons Code Ary city or county which requires a permk lo construct, alter, inwive. demolish, or repair any abitch", prior to its issuance also requires the spoicant for such pwTrK to fife a signed statemment that he Is Ncweed pursuant io the provisions of the ConracW% License Law (Chapter 9 (aormunarg with Section 7000; of Drvtsan 3 or the Busineas and Professions Cade'; or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031 5 by any applicant for ■ permit subjects the Applicant to a civil penalty of not more then five hundred dollars ($500)) [3 1 as owner of the property, or my employees with YAW" as their Sole compensation will do the work and the structure rs not intended or offered for safe (Section 7044, Business and Professioru Code The COntraclDrf License Law does not apply to an owner of property who tit" or Improves thereon, and who does such work h imsellf or through his own empioyees, provided that such improvements are not Iteded or offered for sale. If, however the bud*V or Mnprovenment is sold w0in one year of m copletion the owner -builder will hew the burden of provlg that he did not build or Improve for ft purpose of sale) ❑ 1 as owner of tie property am excknwey, contracting with licensed contractors lo construct the project (Section 7044, Business and Professions Code (B&PC) The ConbacW& License Law does not appy lo an owner of property who builds or improves hereon and who constructs for such projects with a oontrscfor(s licanaed pursuant io the Contractors License Law.) ❑ 1 am exempt under Section .. _ . _ BiPC for this reason Owner ----- WORKERS' COMPENSATION DECLARATION I hereby afffmm that I haw a certiM1cate of consent to sell-Isun or a cartficate of Workers' Compensation Insurance or a unified copy Mhereof (Section 3400 Labpr C") ExpiraUon Data1191111 E Company Z[.� ►-: j�.o fi r!J` lh �c ca O Cerblied copy is hereby turnrshed ❑ Cartfled copy Is Ned w th the Environrner tal Health Dopertrnent CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be Completed if the pent Is for one hundred do" (1100) or less) I car* that I the parbrm&nce of the work for which this pernut is issued: I steal not employ any person I any mercer so as lo become subject io the Wbrlurrs' Compensabon Laws of Caldomis Date: Applicant NOTICE TO APPLICANT If. after me" tihis Cwbficats of Exemption: you should becomma subject 10 the Workers Conpensebon provisaris of tie Labor Cade you must forUnwrth comply with such provisions or this permit shat be dawned revoked CONSTRUCTION LENDING AGENCY I hereby affirm that two Is a oonstnucbon lwdng agency for the perfonrwucs of the wort( for which the permit a issued (Sacbm 3097. CrA Cade) Lenders Name __- Lenders Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby on" that no excavation No (5) or more feet I depth info which a person Is required to deso" wife be made in connection with work auttxinzed by the pwmrt, and that no buddag sbuchxe scafloldirg falsawork or demoMbn or dismentimV Itereot, wilt be more Men Cwrty-aa (36) feet high (Chapter 3.2 Group 2 Article 2 Secbon 341 TRM 8 _ *Atoms AdrtwtntraWe Code). ❑ As owner -builder l w d not employ anyone to do work which wand require a permit hom the DMsbn of I rousbW Safety as now above, runless such person her a pwmil to do such work from the division ❑ Division of Indusbid Safety Permit / j I cwhfy that I how read this applicabon and state tat the above Information is correct. I agree lo coney with all city and county adi anwa and state lawn retebng b wall oonsbucbon and or sewage system const action and hereby authorize representstrws of the county lo enter upon the above-RambOmed property for inspection purposes Dale Applicant I E}i0 t]-@ a0r LICENSED CONTRACTORS DEC -L ATiON a-2aa