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<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 /> 3 7z
<br /> License# �Z3 iratlon Date
<br /> Date Contractor r '95=74&� Z
<br /> .. --� ------ -QWNER-BfiJIGDER-DECLARATION
<br /> I bereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> ( Pxgfessions Code: Any city or county which requires a permit to construct, alter, improve,demolish,or repair any structure,prior to
<br /> its tissuance, 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'exeiription: Any violation of Section 7031.5 by aTy applicant for a permit subjects
<br /> r •the,applicant to a civil penalty offtot�more than five hundred dollars($500)):
<br /> ❑ I, as owner of the property, or my employees with wages is theif sd}e'compensation; will d6.the work, and the structure is not
<br /> intended or offered for sale(Section 7044,Business and`!?rofe's0'ions Code:The contractor's License'Law does n9t apply to an owner
<br /> of property who builds or improves thereon, and who does such woik himself or througli"his own employees, provided that such
<br /> improvements are not intended or offered for sale. If, however, the building or improvement 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 purpose of sale.)
<br /> ( ❑ 1,as owner of the property, am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> I 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 /> w,
<br /> Date: Owner
<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 d� ��
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> 1 CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> I -
<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 /> 1 become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> - r NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> 1 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 /> tff 1 hereby certify that no excavation five (5) or more feeUin 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 permit from the Division of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such wor k from.the civision.
<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
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