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.Joe ADDRESs:W ,I-) Jam✓)IY I��^� PERMrr#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and license is in fill force and effect.
<br /> License# r Expiration Date 123J? 2Q
<br /> Date -� ContractorQ1 ZY'5� -�'1 _� �lt
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions
<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 for such permit to Ni a signed statement 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 Seclion 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars($500)):
<br /> ❑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, Business and Professions 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 himself or through his own employees,provided that
<br /> such Improvements are not Intended or offered for safe. If, howe+rer, the building ,r impmvament is sold within one year of
<br /> completion,the owner-bullder will have the burden of proving that he did not build or Improve for the purpose of sale.)
<br /> f3 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&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(s)licensed pursuant to the Contractor'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 1 have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a
<br /> certified copy thereof(Section 3$40,Labor Code). .. ''
<br /> Expiration Date I-(-�'f'1 Company l//11mad(:� 5j r occ? I/�<
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is fled with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This secllon need not be completed if the Dermit Is fnr one hundred dollars(8100)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: I 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 orthls permit shall be deemed revoked.
<br /> _t
<br /> CONSTRUCTION LENDING AGENCY
<br /> I.hereby affirm that there is a construction lending agency for the performance of the work for which this Dermit Is issued
<br /> (Section 3097,Givii 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,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high,(Chapter 3.2,Group 2,Article 2,Section 341,Title S.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 Safely Permit#
<br /> I certify that I have read this application and slate that the above information is correct I agree to comply with all city and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> 1M-0307 LICENSED CONTRACTOR DC-CLARA'nON
<br /> 70l;>'D7
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