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JOB ADDRESS: 72-45 Oaq h IV E,.?0a l on PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of DIVI°Ion 3 of the Business and
<br /> Professions Cade and my Ilcense is in full force end effect.
<br /> License# 425749 Expiration Date 7/31/16
<br /> Date Contractor C RVA. AND SONS, INC.
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Convaotors License Law for the following reason(Section 7091,5,Business and Profesalons
<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 rot such permit to file a signed Btatement that he is licensed pursuant to the provisions of the Contractor's
<br /> License Law(Chapter 9(commencing 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 more than five hundred dollars(85DC));
<br /> 0 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, Bwslness and Profassiona Code: The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work hlrnself or through his own employees, provided that
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of
<br /> completion,the owner-builder will have the 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,Businsss and
<br /> Professions Code(es,PC): The Contractor's License Law does not apply to an owner of property who builds or Improves hereon,
<br /> and who constructs for such projects with a contractor(e)licensed pursuant to the Conlractar's Ucense Law.)
<br /> ❑1 am exempt under Section , 6&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 Workers'Compensation Insurance,or a
<br /> certified copy thereof(Section 3800,Labor Code),
<br /> Expiration Date Company EVEREST XhTrONAL
<br /> ❑Certified copy Is hereby furnished
<br /> M Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This ser�jon need not be completed if the permit is for one hundred dpILUS($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 Callfomla.
<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 thls permit shall be deemed revoked,
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there i6 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 /> ❑ 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
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falscwvrk,or demolition or dismantling
<br /> thereof, will be more than thirty-six(36) feat high. (Chapter 3.2,Group 2,Article 2.Section 341,Title 8,California Administrative
<br /> Code),
<br /> ❑As owner-builder,I w111 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 1 agree to comply wilh all city and county
<br /> ordinances and state laws relating to wet{construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above,-mentloned property for inspection purposes.
<br /> Date Applicant
<br /> EHO 43-07 LICENs5)00t4TRACr0R oecLARATION
<br /> 1015107
<br /> Received Time—Nov, 20. 2015— 1 ; 56PM—No, 0056
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