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7 ADDRESS, PERMIT if: i LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under the provisions of Chapter o,commencing with Section 7000)of Div isim 3 of rhe Rosiness and Precessions Crude. and my license i>in full force and effect. License k Exp:[)are Dale__ Contractor __. _ OWNER-111111.DER DECLARATION l 1 hereby affirm that 1 am exempt from the Cortraclot's License Law(tic the(ottowing reason(Sec.703 LS.Business and Professions Code: Any city or i county which requires a perndt to construct,aller,improve,demolish.or re^air any structure-prior to its issuance,also requires the applicant for such perm;t i to Me a signed statement that he is licensed pursuant to the previsions of the Contractors License Iaw(Chapter 9 icommencing with Section 7000)of Division 3 of the Business and Professions Cotte)or that he is excnulr he-chem and the basis for the alleged exemption. Any violauon of Section 7031.5 by 11 any applicant for a permit subjects she applicant to a civil penalty of not more than five hundred dollars ($500)): 0 1.as owner of the property,or my employees with wages as their sole Crnupensatiun,wiC do the.work,and the structure is not intended or offered for sate 'Sec.7053,business and Professions Cider The Contractor's Licensc I aw docs not apply to an owner of property who builds or improves thereon,and w-a does such work himself or through his own employces,provided that such improvements are not intended or offered for sale.. If.however,the building or improvement i,sold within one year of cou miction,the owner-builder w:':have the burden of proving that he did not build or improve for the purpose of sale.) O I,as owner of the property,am exclusively cuetracting with Licensed coniracrors to construct the project(Sec.7044,Business and Profession Code:The Contractor's License Lawdoes not apply to an owner of property who Sthereon, udds or improves and who contracts for such project;with a cun(rac!or(s) licensed pursuant to the Contractor's License Law.) D I am exempt under Sm. ,B h P for this reason _.. Date Owner WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self-insure•of a cert ficalc of Workers'Compensation Insurance,or a Cerri5ed copy[hereat!Sec 31300. Lah.C), F.xp.Dole Company_ 0 Certified copy is hereby furnished ❑Certified copy is fled with the Cocnty Building Inspection Divicine CERTIFICATE OF EXEMPTION FROM WORKURS'CONIPENSAI 10*4 INSURANCE (I his.vection need not be completed,if the permit is for one hundred Julian 1$100)or testi T cwtifv that in the performance of the work fur which this permit is iss,:ed.I shall not employ any persun in any manner so as to become subject tot he Workers'Compensation Laws of California. Dale _Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should became subject to the Workers'Cumpensaticn provisions orthe Labor Cade,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY L hereby affirm that there is a construction lending agency for the per`nrmarce of the work for which this permit is issued(Sec.3097.Civ.(7). I Lender's Name_ I I Leader's Address _ I DIVISION OF INDUSTRIAL.SAFETY PERMIT CERTIFIC'AT[ON: Ir 111 hereby certify that no exc•,vatiun five(5)or more feet in depth into whir!•a peison is required to dcsecnd,will be mike in connection with-oil 1 authorized by the permit,and that no building structure.scaffolding,f.,'.sework.or demolition or dismantling thereof,will be more than thirty-six(36)feet II! high. (Chap.3.2,Grp 2,A it 2.Sec 341.Title 8.C.A.0-). ❑As owner-builder,1 Will not employ anyone to do work which W-111 rrqucc a permit from the Division of Industrial Safety,as noted above,unless such person has a permit wdo such work front the division. E3 Division o'Industrial Permit No. I certify that 1 have read this application and state that the above information is correct. [agree to comply with all city and county ordinances and state laws relating to wdl couslmction and or sewage sysam construction,and herchc authorize represenrai i ves u(this city to enter opuu rite above-men tinned property forinslimiion purposes. Date_ :Applicant_ __