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Joe ADDRESS: PERMIT#: I hereby affirm that I an, I' LICENSED CONTRACTORS DECLARATION Professions Code and my license is force and sef fed. the Provisionof Chapter 9 (commencing with on 7�) of Division 3 of the Business License # 9;>.6 and Date -,25ry 7 Expiration Date Contractor OL �utcc� OWNER BUILDER DECLARATION I ICY affcm that I am exempt from the Com' Any � or county which Contractors License Law for the follow) also requires the appy mequires a Permit to construct alter, improve, ng reason (Section 7031.5, Business and P License Law (Chapter 9(commencing m >� Permit to file a demolish. or repair any 1-5, um rofessions herefrorn and the ( mmenci stathrrterrl that he is licensed Anypursuant to the Prior to its issuance, to a civil basis for the alleges exemption.xS on 7�) of Division 3 of the Business and Profession. that Contraclo's Penalty of not more than five hundred dollars violation of Section 7031.5 by any applicant ion Code Ile is exempt 0 1, as owner of the property, or Pertnrt subleds the applicant intended or offered Who Bits � a� Professions Cade compensation. will do the work, and the structure is not sale (Section7044 such of Properly who builds or improves thereon, and who does such work hi contracts'. License Law d ImP1O its are not intended or offered for sale. rrtseff or through o, not apply to an completion, the owner -builder will have If however. the twikB r ° employees. Provided that 1, as owner of the burden of proving that he did not improve °�mProvemerr Is sold within ore year of property. am that contraclin build or im purpose of sale.) an o nsCoie (BaPC): The Contractors License limen OB to construct the project constructs for such Projects With a does not apply to an owner of pro�rty wFlo � �7�• Business and ❑ I am exempt under Section Wntractor(s) licensed Pursuant to the Contractor's License Law.) proves hereon, B&PC for this reason Date: Owner. WORKERS, COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Com certified cePY thereof (Section 3800, Labor Code) Pensation insurance Expiration Date. or a Company 0 Certified copy � herebyfurnished O Certified copy's filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE is section need not be ODm le ted if th it is for one hundred dollars 100 or less I certify that in the Performance of the work for as in become subject to the Workers' Com which this permit is issued, I shall not employ an Date: ,-zt -� pensation Laws of California. P Y Y Berson in any manner so Applicant T NOTICE TO APPLICANT: If, after making this Certificate of Exem Provisions of the Labor Code, p You must forthwith COrnPIY with such Provisions or thispermit shall be deemed subGd to the Compensation ked. I herebyCONSTRUCTION LENDING AGENCY (Section 3097 CI Code). a construction lending agency for the Performance of the work for which this permit is issued Lender's Name Lender• Address DIVISION OF INDUSTRIAL O I hereby car* that no exc,,om i SAFETY PERMIT CERTIFICATION with work autt U e (SPS and non dept into which a�ff� descend, wall he made in thereof. will be more than thi ng structure, required th Code). lily sort (36) feet high. (Chapter 32. Group 2. Article 2. falsework, o d�no6tiwt Or Section 341, Title 8, California Or dis antlinge 0 As ownervbulder, I will not employ anyone to do work above, unless such person has a permit to do which would require a Permit from the D. such work from the division. maston of Industrial Safety. as 'toted ❑ Division of Industrial Safely permit # I certify that 1have read this applkxtion and state that the _ odinartoes and sloth laws to above information is cart to Date county to enter upon the above qty fion or imp on se& em constrtx iot, and hereby authorize o all city Applicant EM 4&0-r raso7 UC6Nsm ccwn'ACroR DECLARATIOU RECEIVE® JUL 2 8 2017 N JOAQUIN COUNTY ENVIRONMENTAL :ALTH DEPARTMENT