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JOSADDRESS: ` � 1�' - ERM1T#:,^
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(cornmencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License# Expir tion Date 3
<br /> Date ..� Contractor y
<br /> ' OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 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 herefrom and 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
<br /> EJ 1,as owner of the property,or my employees with wages as their sale compensation, will do the work,and the stru4ture is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees,provided that such
<br /> improvements are not intended or offered for sale. If,however,the building or unprovemcm is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the ptupose ofsale.)
<br /> 13 1,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 hereon,
<br /> 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 /> E WORKERS'COMPENSATION DECLARA'T'ION
<br /> i
<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
<br /> Certified copy is filed with the Environmental Health Department
<br /> Ih \ CERTIFICATE OF EXEMPTION I-ROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need ggtbe corrtoletedd if the permit is for one hundred dollars f$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 /> Date: Applicant
<br /> NOTICE TO AQPLICANTt If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Cads,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> I
<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 /> oI 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 /> nection with wctk authorized by the permit,and that no building structure,scaffolding,falsework,of drrn lilson 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 /> Coda).
<br /> 13 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.
<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 constructian and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter
<br /> Guppri t e above-inentioued property for inspection purposes,
<br /> DateyG Applicant
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<br /> PHD 43-02-007 MASTER Water Well Pmnit Comradw Declaradion
<br /> 1215/20172
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