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JOB ADDRESS: V S! �i ,Z� �Jy� G+� PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 m licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code ani I my license is in full force and effect. License# 0 S-e S Expiration Date Date /f 2.71 Contractor OWNER-BUILDER DECLARATION I hereby affirm that I i m exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions Code: Any city or co inty which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance, also requires the app Icant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law(Chapte 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the has for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of no more than five hundred dollars($500)): ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not Intended or offereil for sale(Section 7044, Business and Professions Code:The contractor's LIGens.LLaw does not apply to an owner of property Atio builds or improves the d o 1N pr �oFhAm ployee},provided that such improvementsare not intended e r 0 ver, b I r�j��v is old within one year of completion,the o er-builder will have th d n bu r o of sale. ❑I,as owner of the p operty,am exclusive con cti'ng�`wit licensed contractors to const ct th ro ect Section 7044,Business and Professions Code B&PC: The Contractor' }�� p builds or improves hereon, and who construct for such projects with a ct�f}litlfifky1 ifih o actorr's License Lay.) ❑I am exempt under ection �� lowly irrirp��p m � or inspaeLl. Q{�l7Grrr3i 1 Date WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereo (Section 3800,Labor Code). Expiration Date Company ❑Certified copy is h reby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE his section need not be com leted'd the Permit is for one hundred dollars 100 or less certify that in the peformance of the work for which this permit is issued,I shall not employ any person in any manner so as to become Subjecl to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor ode,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency far the performance of the work for which this permit is issued (Section 3097,Civil ode). Lender's Name Lender'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 in connection with wo authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high. (Chapter 3.2,Group 2,Article 2, Section 341,Title 8, California Administrative Code). ❑As owner-builder,1 ll not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such rerson has a permit to do such work from the division. O Division of Industrial afety Permit# l certify that I have read this applicafion and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Date Applicant EHD 43.07 LICENSED CONTRACTOR DECLARATION orsro7