|
JO9ADDRE35: �P.l WV 1� C{r-r—ilf>c QLI. PEaNfrf:..
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code ar�,gry license is in full force and effect �,
<br /> License 7 f �,,` Expiratticin Gate [JDk
<br /> Date Contractor+A[7C[I rx,F Sym t1ec
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contactors License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Ary dry or county which requires a permd an ooramrcl,atter,improve,demolish,or repair any structure,prix to its issuance.
<br /> also requires the applicant for such permit in file a signed statement that he is licensed pursuant to the phwisions of the Contractors
<br /> License law(Chapter 9(comrnendng with Section 7000)of Division 3 of to Business and Profession Code)or that he is exempt
<br /> herefronr and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a pemut subjects the applicant
<br /> to a Civil penalty of not more man five hundred dollars($500))
<br /> O I,as owner of the property,or my employees with wages as their sole compensation,will do the work, and the structure s not
<br /> Intended or offered for sale(Section 7044, Business and Rofessimis Code: The contractor's License Law does not appy to an
<br /> owner of property who builds or improves thereon,and who does such work himseff or through his ori employees.provided that
<br /> such improvements are not intended or offered for sale. ff, however, the building or improvement is 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 /> 0 I,as owner of the property,am exauswey,conhactirg with licensed contractors to construct me project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractors License Law does not appy to an owner of property who builds or improves hereon,
<br /> and who consIncts for such projects with a contractor(s)licensed pursuant to the Cmntractors License Law.)
<br /> O lam exempt under Section _, 8&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 cemficam of Workers Compensation Insurance,or a
<br /> certified copy thereof(Section 3800.Labor Code).
<br /> Expiration Data Company
<br /> ❑Certified copy is hereby furnished
<br /> O Certified copy is filed with the Environmental Heath Departmem
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100)or less)
<br /> I certify that in the performance of the work for which this permit is issued,1 shelf not employ any person in any manner so
<br /> as to become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must fortlmvim comply with such provisions or this permit shat be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued
<br /> (Section 3097,Civil Code).
<br /> Lenders Name
<br /> Landor'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby certify that no excavation foe (5)Or mole feet in depth into which a person is required to descend, will be nude in
<br /> connection with work sumprized by the permit,and that no buliding structure,sratoldlng.falsework,or demolition or dismantling
<br /> thereon,will be more than tarty-six(39)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title e, California Administrative
<br /> Code).
<br /> 17 As owner-bullder,I will not employ anyone to do work which would require a penrtl from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work tram the derision.
<br /> O Division of Industrial Safety Permit#
<br /> I certify that I nave read this application and state mat to above nfomu5on 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 autha¢e representatives of this
<br /> county to enter upon the abcw mertoned property for inspection purposes.
<br /> Date Applicant
<br /> r
<br /> ale+sar DCEraSEp COrrriUCTIXi pECUR1nON
<br /> Millar
<br />
|