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5013 ADDRESS: PERMIT LICENSED CONTRAC'T'ORS DECLARATION I hereby of firm that I am licensed under the prnvisinns of Ct!aptcr 7 cnmc:ancing—h Scclinn 70001 nt Diviskm 3 of the Business and Professions Code. and my license is in full force and effect. License M Exp.Date _- Date__`_Contractor t OWNER•RUILDER DECLARATION ` I hereby affirm that 1 am exempt from the Contractor's License law for the to!:ow•ing reason(Sec.7031.5,Business and P!ofessions Code. Any cit)ur ` • county which requires u permit to construct,alter.improve.,demolish.or repair any structure,prior to its issuance,also requires rhe applicna for srhrh pe rade to file a signed slalemenf that hc.is licensed pursuunt to the provisions ofthe Contractor's License Law(Chup(er 9(commencing with Section 70181)of I Division 3 of the Business and Professions Code)or that he is exempt hurc6iim and the basis for the alleged exemptirn. Any violation of Sectton 71171.5 by any applicant for a pcnrrii sub)ccts:he applicant to a civil penalty of not nin–than Five hundred dollars (S51AI)e. ❑1.as owner u(the pfnpcny,or my employees with wages ams their sole ov•nh{ensatiom.will du dm work,and the stricture is not intended or offered for sates I (Sec,7044.Business and Professions CrAc:The Contractor's License Lau.L)es nor apply to an owner of pr gxaty u-ho builds or miprovts thereon.and who docs such work himself or through his own empinyces,provided that.much Improvements are not intended or offered for snlc. If,hnwcvcr,the building or improvement is told within one year of completion,the nwncr-builder a i1:base the burden of proving chat he did not build or improve for the purpose or safe.) D 1,as owner of the property,um exclusively contracting with licenced crn•Iractors tocon.vn:ct the prnjccl(Sec.7()4s•Business and Profession Code:The Conlractor's License Law does not apply to an nwrcr of properly who bul.ds or improves thereon,and who contracts for such projects with a conmaclor(O licensed punuanl to the Contractur's License Law.) ❑1 am exempt under Sec. -" ,B R P.C.for this mason ff I DateOwner .-�--- _ WORKERS'COMPENSATION DECLARATION ! I hereby affirm that I have a certificate of consent to self-insure,ora:cntf icate nt Workers'Compensation lnsuraur,nr a vcnifed cony thrmof f Ser.Mxu, Lib.Cl. Csp.Datc Company_ i O Certified copy is hereby furnished ❑Certified copy is Tiled with the County Building Inspection Divi—o ! CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE j (This section need not be completed,of the permit is for one hundred doll.irs iS IM)or lett) ' ' I certify that in the performance of the work for which this permit is is.oed.I shall not employ any person to any manner so as to become suhiect tot he Workers'Compensation Laws of California. I I Drxe Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exempelou.you should become sul!MCI to the Workers'Compensation prnvisinns of the Labor Code,you must:forthwith comply with such provisions or(his rermu ..hall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for due perlurmance ul'the work for which this permii is issued(Sec.3097.Civ.C). Lender's Naune _ -- LnWer's Addrm.4 ' DIVISION Or INDUSTRIAL SkFETV PERMIT CERTIFICATION: I j ❑1 hereby cenity than ro excavation five(5)or more feet in depth Into a Mali a person is required to de xend.will he make in room-tion with work authori7d by the permit.and that no building siruclure.scaffolding.lal.cu,rk.or demnliti v)or dismantling thereof.will be more than thirty-six(36)feet Ingh. (Chap.Ai Grp 1 Ads 1,Sec 331.Title g.C.A.C.) ❑As owner-builder,twill nix employ anyone to do work which wnulJ trgarc a Fwrmn from the Thy inion of Industrial Safety,as noted above,unless such person hams a permit to du such work from the division. ❑Division of 11 Justrial Permit No. I cenify than I have read this application and slate that the above mfennatirn is correct. I agree to comply with all city and county ordinances and state laws relanng to well construction and sir sewage sysicm construction.and herehr authon7e repreuntmives of This city to enter upon the nbuve-memiunctl property for inspection purposes. Dare Applicata _