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JORADDRESS: PERMIT#:
<br /> s _ LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)+of Division,3 of the Business
<br /> and'Professions Code and my license is in full force and effect.
<br /> License# Expiration Date `
<br /> Date" Contractor —
<br /> OWNER-BUILDER DECLARATION
<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 requires 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 herefromland the basis for the alleged exemption. Any violation of Section 7031.5 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 /> ownei 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,howeve the building or improvement is sold within one year of
<br /> completion,the owner-builder will have the burdeA'of proving that he Idid 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 /> - r
<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 certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy'is hereby furnished r '
<br /> ❑Certified copy is filed with the Environmental Health Department
<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,I shall not employ any person in any manner so as to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> a ,
<br /> Date: Applicant
<br /> NOTICETO 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 performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code)-
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ 1 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 pernut.from the Division of Industrial Safetyas
<br /> Y
<br /> noted above,unless such person has a permit to do such4work from the division.
<br /> ❑Division of Industrial Safety Pemut#
<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
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<br /> EHD 43-02-007 _. '-, j f II. _ - �� �L•LICENSED CONTRACTORS DECLARATION-'
<br /> 12/11/2002
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