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JOB ADDRESS: PERMIT P: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and <br />Professions Code and my license is in full force and effect <br />License # SZ_pn 1-� _ Expiration Da/t�e� 62 <br />Date Li– /Z—/ fJ __- - - Contractor NA"., <br />OWNER -BUILDER DECLARATION <br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions <br />Code Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, <br />also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's <br />License Law (Chapter 5 (commercing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt <br />herefrom and the basis for the alleged exemption. Any violation of Section 7031 5 by any applicant for a permit subjects the applicant <br />to a civil penally of not mae than five hundred dollars ($500))' <br />❑ I, as owner of the property, or my employees 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 properly who builds or improves thercon, and who does such work himself or through his own employees, provided that <br />such imFrovements are not intended or offered fur sale. If, however, the building or improvement is sold within one year of <br />completion, the owner -builder will have [tie burden of proving that he did not build or improve for the purpose of sale.) <br />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and <br />Professions Code (BBPC) The Contractor's License Law does not apply to an owner of properly who builds or improves hereon, <br />and who constructs for such projects with a conlractor(s) licensed pursuant to the Contractor's License Law.) <br />❑ 1 am exempt under Section , BRPC for this reason <br />Date: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm that I have a certificate of consent it sell -insure or a certificate of WorkersCompensation Insurance, or a certified copy <br />thereof (Section 3800, Labor Code). <br />Expiration Date _ Company <br />❑ Certified copy is hereby furnished <br />❑ Certified copy is filed with the Environmental Health Department <br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br />(This section need not be completed if the permit is for one hundred dollars ($100) or less) <br />I cenily that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to <br />become subject to the Workers' Compensation Laws of California. <br />Dale: <br />Appllca <br />NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation <br />provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. <br />CONSTRUCTION LENDING AGENCY <br />I hereby affirm [hat there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. <br />Civil Code) <br />- <br />Lender's Name <br />Lender's Address <br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br />O 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, vnll be made in <br />connection with work authorized by the permit, and that no building structure, scaffolding, faisework, or demolition or dismantling <br />thereof, will be more than Ihiny-six (36) feel high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative <br />Code), <br />❑ 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 to do such work from the division. <br />❑ Division of Industrial Safety Permit # <br />I cenily that I have read this application and state [hal the above information is correct I agree to comply with all city and county <br />ordinances and slate laws relating to well construction and or sewage system construction, and hereby authorize representatives of this <br />county to enter upon the above-mentioned property for inspection purposes. <br />Date <br />Applicant <br />EHD 43 -02 -ON IICEN6EO CONTRACTORS DECLARATION <br />62G-0- <br />