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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter J(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License# S I O 161 Expiration Date Date Contractor -4, f y"l��dr+r�✓ f-(evnA••dcz Pf-c OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, orr air any structure, prior to its issuance, also requires the applicant for Qr S"i statement that he is licensed suant to the provisions of the Contractor's License m , of Division 3 of the Busine and Professions Code) or that he is exempt herefromt a. i violation of Section 7031.5 any applicant for a permit subjects the applicant to a civil den f' than five hued®, 500)): ❑ I, as ownlM"O* rrw �I�Q g es as their sol om ensation, will do the work, and the structure is not intended o[r 'I�P4� 9t Wss ind Professio Code: The contractor's License Law does not apply to an owner of liE WO ds�.�`I WFInd who does ch work himself or through his own employees, provided that such impr 4 i �o f�ered for sale. If, wever, the building or improvement is sold within one year of completion', a owner-builder will have the burden of proving t t he did not build or improve for the purpose of sale.) ❑ I, as owner of the property, am exclusively contracting wit censed contractors to construct the project(Section 7044, Business and Professions Code (B&PC): The Contractor's License w does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contracto s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Section , B C for this reason Date: wner• WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certi i e of Workers' Compensation Insurance, or a certified copy thereof(Section 3800, Labor Code). Expiration Date Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental alth 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 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. �+a v-e � /'7/2 vvr w n CZ Date: '��°�� Applicant G-psz 0, k A .. 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 RTIFICATION ❑ 1 hereby certify that no excavation five (5) or more feet in depth into whi a person is required to descend, will be made in connection with work authorized by the permit, and that no building stru re, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chapter 3.2, Grou , Article 2, Section 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which wou require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from t division. ❑ Division of Industrial Safety Permit# I certify that I have read this application and state that th above information is correct. I agree to comply with all city and county ordinances and state laws relating to well construction an r sewage system construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for i pection purposes. Date Applicant EHD 43-07 LICENSED CONTRACTOR DECLARATION 10/5/07