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Joa ADDRESS: 1--e A A #GTJh—L Jt� �L�.Z4EIRMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Di 'sion 3 f the Business and
<br /> Professions Cod i ns is in full force and effect. l�
<br /> L en s@ piratic Date 1 �l
<br /> Date Contractor
<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,atter,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 pursTanto th rovi s o thnLicense Law(Chapter 9(commencing wth Section 7000)of Division -d81ltsil�is 4PI,
<br /> ns o exeherefrom and the basis for the alleged exemption. Any violation of SaEtiil E � 's!' i nt
<br /> to a civil penalty of not more than five hundred dollars($500)): ' 7
<br /> l )two
<br /> ❑ I, as owner of the property,or my employees with wages as their dole compensation, II do the work,and a��re I��s}not
<br /> intended or offered for sale(Section 7044, Business and Profassiona� l h ' � s fC9WCJl�lan
<br /> owner of property who builds or improves thereon,and who does such Urik�ilm'se' o through rs o emp oyses,provided th t
<br /> such improvements are not intended or offered for sale. If, hawgk4lhatiifg Qnpfp�spfMvjstgp �l�f
<br /> completion,the owner-builder will have the burden of proving that hb' }}�i�� yy�rl�l�A* bf 4a1A) N"
<br /> ❑1,as owner of the property,am exclusively contracting with licensed ��f�� r�c �l ,� nd
<br /> Professions Code(B&PC): The Contractor's License Law does not a ly to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contradnr's License Law.)
<br /> ❑1 am exempt under Section , B&PC for this reason
<br /> Date: Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of .orkers'Compensation Insurance,or a
<br /> certified copy thereof( ecti n 3800,Labor Code), C
<br /> Expiration Date `�� Company
<br /> ❑C rtified copy is here y 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 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so
<br /> as to become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<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 that there is a construction lending agency for the performance of the work for which this permit is issued
<br /> (Section 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> *I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(38)feet 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 certify that I have read this application and state that the above information is correct. I rr gree to com with all and county
<br /> ordinances d state It"relating to well construction and or sewage system constru on,a �rby utho�ze repress tives of this
<br /> county to r u on th above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-07 LICENSED CONTRACTOR DECLARATION
<br /> 1015x07
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