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(/1 I Job ADDRESS: '" I�] `� ?7 �d PERMIT wy- LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of pte 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license its in fu force and effe License# Ex ration Date C� JLI f ( l✓ Date Contr X� _ f b4&-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lavr for the following reason(Section 7031.5.Business and Professions Code: Any city 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 a signed statement that he is licensed pursuant to the provisions of the Contractor's License Levi(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 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars($500)): O 1,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 contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) I,as o.vner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): 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 bursuant to the Contractor's License Levi.) ❑I am exempt under Section B&PC for this Reason y i - Date: S [ Owner: WORKERS' SATION DECLARATION hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof( ection 3800,Labor Code). \ f Expiration Date C� Company ❑Certified copy is hereby furnished , Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'CO PENSATION INSURANCE This section need not be completed if the permit is for one hundred dollar 5100 or less I certify that In l e perfomtance of the work for which this per. is issue I shall not employ any person in any manner so as to become, bjec o the Workers'Compensation Laws of rni Date: S� Applicant ~ NOTICE TO APPLI ANT:If,after making this Certificate of a n, you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with c isions 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). Lenders Name Lender Address 1 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION khereby certify that no excavation five(5)or 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 structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title B,California Administrative Code). ❑As owner-builder.1 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[hat I have read this application and stale that the above information is correct. I agree to co y with all city and county ordinances and spate it relating to well construction and or sewage system construction,and hereby at Dr ze representatives of this county!o en n Ih aowe-mentioned property for inspection purposes. / Date Applicant / V EKD 43.07 LICENSEO CONTRACTOR DECLARATION I C15;07