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- . Ltl,Gi�At+L C.Vl�ttltfl.i"VA.7 1JGl.LHrill.ttVi�
<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 /> License# 3779a� ExpiratioPJDqte
<br /> Date Contractor -
<br /> -
<br /> OWNER-B'U[L;DER D-ECI,ARATION
<br /> I hereby,affirm.that I 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 SeQtwn_7009X of Division 3 of the Business and Professions Code)or.that he
<br /> is exempt herefrom and the basis for-the alleged exemptiom.,Aji�violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applic int to a civil penalty of not more than five hundred dollars(1500)):
<br /> 0 I, as o er of the property, or my employees with wages as their sole compensation, will do the work, and the structure 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 /> j of property who buil&or improves thereon, and who does such work himself or through his own employees, provided that such
<br /> improvements are not ttende r offered,for•sale._.If�h�Yer,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 /> { I, as o er of the pfoggrty, am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> q and Profe signs-Code.(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br /> and who gonstructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> 0 I am exempt under Section B&PC for this reason
<br /> V
<br /> Date: Owner
<br /> t WORKERS'.COMPENSATION DECLARATION
<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 /> icopy thereof(Section 3800,Labor Code).
<br /> Expiration Date �'�-0'� Company .
<br /> All
<br /> 0 Certified copy is hereby furnished -
<br /> •,�Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> l
<br /> (This section need not be completed if the permit is for one hundred dollars MOO)or less)
<br /> f 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 APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> 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 /> I 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 /> 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 /> 0 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 ftom the division.
<br /> 0 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 relatine to well construction and nr sewave systeoae�++, ictinn. and herehv anthnrize representatives of this
<br />
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