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PERMIT • JOB ADDRESS: PERMIT#'� � •_ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. G License 130��3 Oz. qs' Expiration Date# Date J&1ILt Contractor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for 1 I eaeen tion 7031.5,Business and Professions Code: Any city or county whi h regiNr p, o u a[e� o li re it any structure,prior to its issuance, also requires the applicant fot s e f b i n stat n al e u t to the provisions of the Contractor's License Law(Chapter 9(com n9 0 of th sl n rofessions Code)or that tie is exempt aIle a �n violation of Section 7031.5, any plicant for a penult subjects the applicant herefrom and the basis for tha � to a civil penalty of not more than rive h��u►n�dryye dollar(Shoe py(}�(�ed { �U ❑ I,as owner of the property, oriirt�rettlpl f�Tslr �a/ 'wia(g�esVas ttheer.1sole A, -,�,rvv��77I do the work, and the structure is not mended or offered for sale(Se tl �kabloug License Law does not apply to an owner of property who build6..'Qt f � t does such o him6el r rough his own employees,provided Ihat �� jh kAgamprovement is sold within one year of such improvements are not in ende or o�fTgr 1 a fit?tl of build or improve for the purpose of sale.) completion,the owner-builder VA411*11EW +P with rensed contractors to construct the ct ❑IP ofessions Code(B&PC):aTheeContracyto contracting s L cense Lawlldoes not pply to an owner of property who 044,Business who bu ds orimp improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) ❑1 am exempt under Section . B&PC for this reason Date: Owner: 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 thereof(Section 3800,Labor Code). �i Expiration DateIrhd4Y Company ACertified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100)or less) I certify that in the performance of the work for which this penult Is Issued.I shall not employ any person in any manner so as to become subject 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 Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five (5) ur more feet in depth into which a person Is required to descend, will be made In connection with work authorized by the permit,and that no building struct ftoSecgona341 T tiork,e8,Cal'iforrrnia Adml n st altive thereof,will be more than thirty-six(36)feet high. (Chapter 3.2, Group 2, Art cle 2 Code). ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Permit# I certify that I have read this application 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 LICENSED CONTRACTOR DECLARATION EHD 43-07 1015107