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PJOISAI:)DRESS: ?)-eck�nan r L-Q�i PEMT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under tie provisions of Chapter 8(un Professions Code and my license Is in full force and effeat, g w1h Section 7001)Of Dfvlslon 3 of the Business aad License#_P,Date `�/ G1 r Expiration Date C{ 50/2-li?iC d Z'� i COntractor_ CCL��tz:Ytl.1Gt 6-�-n,4-,c"c,�t OWNER-BUILDER DECLARATION I hereby affirm that i am exempt from the Contractors License Law for the following reason(Section 70315, to Code: Any city or county which requires a permit o construct alter, Business and Professions improve,demolish,or repair any structure,prior to its issuance, a signed statement that he is licensed pursuant to the provisions of the Contractors also requires the applicant for such permit to file License L2%v(Chapter a(commencing With Section 7000)of Division 3 of the Business and Professions Code)Cr that he is exeWl 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 penalty of not more than five hundred dollars($500)): ❑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 or 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. Ir,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 or the purpose of sale") O I,as owner of the property,am exclusively contracting with licensed contractors to construct the PMW(Section 7044 Business and Professions v hoeconstructs for projects with a contractor(s) cenThe Contractol's License Law sednot Pursuant o the Corttractor'ly to an owner Of roLce sese La fids or Improves hereon, ❑1 am exempt under Section , B&PC for this reason Date' Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certfficate of Workers'Compensation Insurance, thereof(Section 3800,Labor Cade), or a certified copy Expiration Date Company C3 Certified copy is hereby furnished 0 Codified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE hir.section need not be cam sited f the .rmit is for ono hundred d s S100 aria I certify that in the performance of the work for which this permit' a. shall note b become subje/ct o the Workers'Compensation Laws of Califo y any Person!n any runner a a o Date: y l--L �flj Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the VVorkers'Compensation Provisions of the tabor Code,you must forthwith Comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 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). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION AOhereby certify that no excavation fire(5)or more feet in depth into which a person is required to descend,Wil be made in connection with work authorized by the permit,and that no building structure,scaffolding,faksework,or demolition or dismantling thereof,Will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Articre 2,Section 341,Title 8,California Administrative Code). ❑As owner.bu leder,I 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. O Division or Industrial Safety Permit M I certify that I have read this application and state that the above information Is ordinances and state lays relating to well construction and or sewage system con I agree to comply with all city and county county to enter upon the above-mentioned property or inspection purpos,s. d hereby authorize /[ 1 representatives of this �/Date ' r � Applicant EiD 43.02.007 6.26-03 LICENSED CONTRACTORS DECtARA-nCN