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c t JoBADDRI:ss: ! J ( r PERMIT#: LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chep r ( mencing wi Section 7000)of Divislon 3 of the.B siness and Professions Code and�};lice se s In ill force end effect. Q License# f "t�0�LO !ra Date Contractor OWN R. ILDER DECLARATION I hereby affrm that I am exempt from the C.ontractor's License Low for the following reason'(Section 7031,0,Business and Professions Code; ,Any ply or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its issuance, also requires the applicant for such permit to file s signed statement that he Is licensed pursuant.to the provisions of the Contraclor•s License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.6 by any applicant for a permit subjects the applicant to a civil penalty of nel.mo(e than five hundred dollars($500)): E3 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 offered for sale(Section 7044,Business and Professions_Code:The contreotor•s License Law does not apply to an owner Of property who builds or improvesthereon,and who does such work himself or through his own employees,provided that such 1ptprovements are not Intended or offered for sale. It, however, the building or Improvement is sold within one year of 9ompledon,the owner-builder wilt have the burden of proving that he did not build or Improve'for the purpose of sale.) .F�1I,as owner of the property;em exclusively contracting with licensed contractors to construct the project(Section 7044;Business and Professions Code(B&P.C): The Contractor's License Law does not apply to an owner of property who builds or 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 f Date: l Zr Owner: WORKERS OMPENSATION DECLARATION I hereby affirm that I.have a certificate of consent to self insure ora certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company Certified CDpy Is hereby furnished Certified copy is tiled with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not bg Completed if tit ermit Is for one hundred dollars(51001 or fess) .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 Lav Callfornia. Date: App)Icant_ NOTICE TO ApPLII T:If,after making this Cerullcale xemption,you should become subject to the Worke ompensetioh provisions of the Labor Code,you musffortiiwllh comply rr such provisions or this permit shalt be deemed revoke CONSTRUC E 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). t // Lenders Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 1f]I hereby certify that no excavation rive(6)or more feet in depth Into which a person.Is required to descend,will be made In connection with work euthor[zed by the permit,and that no building struclura;scaffolding,falsework,or demoll6on.ordismantling thereof,will be more then thirty-six(3e)feel high.(Chapter 3.2,Group 2,Article 2,Section 341,Title B.Califomia Administrative Code). O As ocmer-bu➢der,I will not employ anyone 10 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. O 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 It and c ty ordinances and state laws relating to well construction and or sewage system construction,and hereby orize representative is county to enter up t e ab a-n boned property for Inspection purposes. Date�� t Applicant EHO 43.07 'iN5N7 LICENSED CONTRACTOR DECLARATIOil