|
JQB ADDRESS: PERMIT#:
<br /> i 0 , J^
<br /> LICENSED CONTRACTORS DECLARATION f
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section of Division 3 of the Business
<br /> and Professions Code:and my license ism full force and effect. ) d:`�,-:, , . w ,
<br /> 3
<br /> License#, ti' ¢• �`
<br /> � , � .� Expiration Date
<br /> Date = Contractor 1 r
<br /> OWNER-BUILDER DECLARATION F .•
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which require's,a permit to construct, alter, improve, demolish, or repair'any structure'(prior to
<br /> its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 703I.5 by any applicant for a permit subjects
<br /> the applicant 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 sale. If, however, the building or improvementis sold within one year of
<br /> completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br /> and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
<br /> ❑ I am exempt under Section B&PC for this reason
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers' Compensation Insurance,or a icertified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is'filed with the Environmental Health Departinent x y tet- "
<br /> _ s
<br /> 5 � 4,-
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if thepermit,is„for one hundred dollars($100)or less) - 1
<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 as to f
<br /> become subject to the Workers' Compensation Laws of California:
<br /> I 1i
<br /> Date: Applicant 1 �f
<br /> NOTICE TO APPLICANT: If, after making this ,Certificate of;Exemption, you should .become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> : ! CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the perfo'rmance'of the work for which this permit is issued(Section
<br /> 3097,Civil Code). t t
<br /> Lender's Name ;
<br /> Lender' Address
<br /> A
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑.I 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 8,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
<br /> noted above,unless such person has a permit to do such work from the division. t`
<br /> ❑Division of.Industrial Safety Permit#
<br /> I certify that I have read this application and state 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 /> EHD 43-02-007 L[CENSED CONTRACTORS DECLARATION
<br /> 12/11/2002
<br />
|