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JOB ADDRESS: PERMIT k: LICENSED CONTRACTORS DECLARATION I hereby affsrfn lmlI am licensed under the previsionsof Clupmrt)(cammew ng with S«tion 7(M)of Di vision 3 of the Business and Pmfessiom Cade, and my license w in full force and eRwt, Limesc M Esp,:parc Date Contractor OWNER-BUI LVER DECLARATION I hcrcby affirm rent l vm cxempl from the Com ecou-s Liam Lw forme following reason(Sue.7031.5,Business and Prokubns Code; Any city ar county which requires a permit to coaswu.atter,improve,demolish,err mpav any tinware,prior to l4 issuance,alio requirts Ibe applicmm fa sacs permit to file a signed rtYoment thmt m is licensed pursuant w the provisium nhhc Conoacwr's IJecnse Lw(Chapter 0(comtrcndng with Section 7110))or Division3of the Business arW PmGasinm Code)or Nat M1c is escrrspt herelrom and dw basis(err the alkgal ucmgioa. Any violation mrSartimr 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (3500)): O L utowner of the properly,err my amployea with wage as initiate compvnsmion,will do the work,and the suucwre is nd intended or afford For sale (Sm.7044,Buslnns and Professions Code:The Commolor's Licaur Lw dos nor apply to an owner of pmpeny who builds m insproves thermal,arta who dors such work himself or through his own employee,provided that such inprovcmmus arc not intendnl"offered for sale. If,l v,o,r,the building a improvement is sold within one year of cominciion,tits owner-builrkr wtd hale the human of proving Out he did not build or improve fa the purpose of sale.) 111.os owner of the property,am asclusively continuing with keened contractors m cocamea the project(Sec.7044,Business and Pmkssion Cada:The CoMilimor's Liana Inco docs nor apply to an owner of property who bwlds or improves Ihmeun and who contracts for such projects with a commicaur(A licensed pursuant to the Committee's Lkense Lw.) ❑I am exempt under Sm. ,0&P.C.for dus reason Dae Owner WORKERS'COMPENSATION DECLARATION I hcrcby from that l have acenificanc or earscnUo self-insula.a ceniBmm of Weasels'Compsmami et lmorana,or a cenified copy thereof(See.3g110, Lb.Q. Exp.Doc Company ❑Cenifred copy Is hcrcby(amiaboad ❑Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE t (This section need not ba completed.if the permit is for one hundred dollars IS 100)or k s) I certify that in race performance of the work for which this permit is issued.I shall nm employ any perms in any o sumer so m m become subject to the Worsen''Compensation Laws of California. - - D21i Applicant - - NOTICE TO APPLICANT:If,after making this Ccniftase of Exemption,you ihmrld become object to the W.fla rn'ComPomaton provisions of Its, Labor Cale,you must forthwith comply with such provisions m this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hcrcby affirm that shw is a canswdion lending agency for the performance of the work for which this permit is issued(Sm.3077.Civ.Q. Lender's Nor LMer's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O I hereby cannily that no excavadm five(5)a more far in depth into which a person is required to dnqnd,will be,mo ke in conoatim with wok ¢umorixed by the psamiL am that an building suumurc,scaffolding,fal.wworh,or demolition or dom undmg thereof,will be rrwrc than thiri(M)fat high. (Chap.3.2,Gg2,An2.Sec341,Tldag,C.A.C.). ❑As ewer-builder,I will not employ anyone m do work which would require n Ismmit From the Divisim of Industrial Safety,as twkd above,unless such person has a perms m do such work from the division, ❑Division of Indashi,id Permit No. I certify Nall Rave leerd W¢up4licmion and ssatcthause above informatim�is wrest. Lagne tocomply with all city and countyordinances and state laws relating w well combustion and or sewage system c...mciine.and hammy authume,rprocnmti via of this county a ender or=the property for inspection purposes. above-nsentioncd Date Applicant 1y'