WP0039532 - Laserfiche WebLink

Home Browse Search

JOBADDRESS:- I Y� ___ A� — PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am liconsed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is In full force and effect. q �q License#. QLq_ 5 Expiration Date I' �_!_J—_-- p� -- Date__ 1.�- -► .— Contractor— 9r 4� 1�_V_ . �ra OWNER-BUILDER DECLARATION I hereby affirm Ihal I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Duslness and Professions Cade: 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 Law(Chapter 9(commencing with Section 70D0)of Division 3 of the Business and Professions Code)or that he Is exempt herefrorn arid 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($500)): M I, as owner of the property,or my employees with wages as their sole compensation,will do the work,arld the structure is not intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees•provided that such improvoments are not intended or offered for sale. If, however, the building of improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) U I,as owner of the property,am exclusively contracting with licensed conlrectors to construct the project(Section 7044,Business and Professions Code(B$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 contiactor(s)licensed pursuant to the Cuntrarloi's License Law.) - — - Cl t am exempt under Section B&PC for this reason Date: Owner ---- -- j WORKERS'COMPENSATION DECLARATION ( i hereby affirm that 1 have a ceilfficate of consent to self-Insure or a t�encate of Workers'Compensation insurance.or a certified copy I thereof(Sachin 3800,Labor Code)- S l ElupkrationDate__ - aQa � 1a Company l! QGADA IFr I U Certified ropy Is hereby furnished e L3 Certified copy Is filed with the Erwironmentai Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (ThLi section need not be completed if the permit is for one hundrad doilars f$1001_or less) [ 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 Wor'.ters'Compensation laws of California. Date: Applicant -- ---- NOTICE"f0 APPLICANT: If,after making this Certificate of Exemption,you should become subject to the workers'Compensation t provisions of the Labor Code,you must forlhQi)comply with such provisions 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 Ls Issued(Section 3097, till Civil Code). Lender's Name -- - Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION Ll 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 ! connection with work authorized by the permit, and that no building structure,scaffolding,falsewoik,or demolition or dismantling thereof,will be more than thirty-six(30)feel high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative Code). E As owner-builder,I will not employ anyone to do work which would regime a permit from the Division of Industrial Safety,as rated above,unless such person has a permit to do such work from the division. L1 Division of Industrial Safety Permit ft I Lerfify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the abovo-mentioned property for inspection purposes. (: Date ---- Applicant _`-----__-_-._-_-- __.--- i` t EHD 43-02.007 L IC ENSED CON r"G I ORS DeCLARA110N 19.26 09 i