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i I. JOB ADD1trm: _ PERMIT 9: LICENSED CONTRACTORS DECLARAITON I hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business i and Professions Code and my license is in full force and effect. License# Expiration Date r Date Cautraeter OWNER-BIIILDER DECLARATION P I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code: 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 sided statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he $, is exempt herefiom and the basis for the alleged exemption. Any violation of Section 703I.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollans(000)); 0 I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not untended 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 in proves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,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 for the purpose of sale.) E3 1,as owner of the property,am exclusively contracting with licensed contractors 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 contmetor(s)licensed pursuant to the Contractor's License Law.) D I am exempt under Section B&PC for this reason + Date: Owner f W0 1t14XW COMPENSATION DECLARATIDN I hereby affirm that I have a certificate of consent to self-insure,or a oerti'frcate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Compaay k 17 Certified copy is hereby furnished �j ❑Certified copy is filed with the Environmental Health Department CERTITICATE OF EXEMPTION FROM WOFJURS'COMPENSATION INSURANCE (T-1tis section need not be completed if the nemdt is for one hundred dollars($100)or less) 1 certify that in the performance of the wont for which this pernfit is issued,I sball not employ any person m any manner so as to become subject to the Workers'Compensation Laws of Califomia. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of-Exemprion'you-should become subject to the Workers' Compensation provisions of the Labor Cade,you must forthwith comply with such provisions or this permit shall be deemed'revoked. ' CONSTRUCTION LENDING AGENCY I hereby affirmthat there is a construction lcstding agency for the perfaumance of the work for which this permit is issued(Section . . 3097,Civil Code), i bender's Name Leader'Address DIVISION OF INDUSTRIAL 5AF$TY PERMIT CERTICATION + 0 I hereby certify that no excavation five(5)or mare 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,falsework,or demolition or dismantling ` thereof,will be more than thirty-six(36)feet high(Chapter 3.2,Cmup 2,Article 2,Section 3.41,Tide 8,California Administrative + Code), ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as I noted above,unless such person has a permit to do such work from the division. 13 Division of Industrial Safety Permit# 1 certify 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 above-mentioned property for inspection purposes. Date Applicant 011)43-02-047 MASTER Wager Well Parade jCmnctDr Declamctlon 11/5/2042 T