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' JOB ADDRESS• _ PF.Rat1T tY: . LICENSED CONTRACTORS DECLARATION ' I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License# Expiration Date Date - Contractor - OWNER-BUD'.DER DECLARATION ' I hereby affirm that I am exempt fiom the Contractor's License Law for the following reason (Section 7031.5, Busineis and Professions Code: Any city or county which requires a pemdt to construct;alter,improve,demolish,or repair soy strumi ,prior to its issuance,also requires the applicant for such permlt to file a signed statement that he is licensed pursuant to the provisions of the Contractor's Liecose Law(Chapter 9(coltmmencing with Section 7000)of Division 3 of the Business and professions Code)or that he ' is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hrmdred dollars($500)): 0 I,as owner of the property,or my employees with wages as their sole compensatirm, will do the work and the stmcmre is not intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner ' of property who builds or improves thereon, and who does such work himself or through his own employees,provided that such improvements are not mended or offered for sale. If,however,the building or improvement is sold within one year of completion, the owner-budder will have the burden ofprovmg that he did notbuild or improve for the purpose of sale.) O 1,as owner of the props ry,am exclusively contracting with licensed contractors to construct the proimt(Section 7044,Business ' and Professions Code(B&PC): The Contractor's License Law does not applyte an owner of property who builds or improves hereon, and who eori mucts for such projects with a conuacmr(s)licensed pursuant to the Contractor's License Law.) O I am exempt under Sectio¢ , B&PC for this reason ' Date: Owner WORKERS'COMPENSATION DF!'r ARATION ' I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation,Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company ' 0 Certified copy is hereby furnished O Certified copy is filed with the Environmental health Department ' CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be com¢leted if the nerrmt is farone-bundred dollars($1001 or less) 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 become subject to the Wolters'Compensation Laws of California. ' Date: Applicant NOTICE TO APPLICANT: IC atter mating this Certificate of Exemption, you iho'old become sutiject to the Workers' Compensation provisions of the Labor Code,you most£ortbwith comply with such provisions oribis permit dull be deemed revoked. ' CONSTRUCTION LENDING AGENCY. I hereby affirm that them is a construction lending.ggency for the performance of ilk work for which(bis permit is issued(Section 3097,Civil Code). _ •- loader's Name Lender'Address ' DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION Cl I hereby certify that no excavation five(5)or more feet in depth into which a person is required m descend, will be made in connection with work authorized by the permif,and that no building structure,scaffolding,falsework,or demolition or dismantling ' thereof, will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative Code). 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a pemtit to do such work from the division. ' 0 Division of Industrial Safety Permit# _ I certify that I have read this application and state that the above information a correct 1 agree m comply with all city and county ordinances and stage laws relating to well construction and or se s,Xkm construction,and hereby authorize representatives of this county m enter upon the above-mentioned property for inspectionapi� pot. ' Date Applicant EMD 43.02-OW MASTER WaW Well Pernik Convector Dectaraclon 5121U2002 j.