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JOB ADDRESS: PERMIT p: LICENSED CONTRACTORS DECLARATION 1 hereby affirm that Item licensed undo rho proviamus of Chapter 9(enarmcnring with Section 71)(1(1)af Division 3 of tM Rusines5 and Prulssloes Codes mid my lieenac is in full force and effect. License x Esp.:D.m Dam Contract OWNER-BUILDER DECLARATION 1 hereby affirm des I am exemm foam the CommnaPs Licrnsa Law for the following reason(Sec 7031.5.Rusixss and Professions Cade:Any city or county which requires a permit to mati"ct,alter,improve,demolish.at repair any structure,pnor to its issuance,also.quims the applicant forsuch permit to file a signed statement that he is licensed pursuant to the provisions of the Contr car's License law(Chapter 9(a m rnmeing with Section 71M)of Divisian3 ofrM Bus)ncss and Pro(essinns Codc)ar Nm he is exempt herclram and the basis(or the.Ilcgcd uemptias. Any vio6 tion of$ediin 7031.5 by any applican[fo a permit subjcc6 the applicanuo a uvi7 pewlty of sot moa than five hundmd dollars ($500)): ❑1,u oamarof the pmPerfy,army employees wills wages as their role compeasadon,will do IM work,and Bre."core is na immndrd or oRered for vle (Sec.7044,Business and Professions Cad.The C ...moor s L)auia law does not apply Ice an owner of property who builds or iirpravo Iberian.and who dors such work himself or through his own employar,provided thm such improvements are nor intended or offered forsale. If,however,rM building a improvement is sold within one year of campahon.the owner-builds was:haw the burden of proving that lye did no build or improve for the purpuae of i sale.) O I,ms owner of the propmny.am c.dusivcly contrxting wi0licensed wn"c.rs to cons"u the pmjctt(Sec.iW 4,Business and Pmfessien Code:The Coavacar's Li n to law docs nm,Lily m an awns of prapeny who bolds ur impoaves Ihueon.xd who enntmers far such pmj«ts with a mnvartugc) licensed Initiation to the Comrxar's License fawJ 111 am except under Sec. 0 ge P.C.pandas reson Dare Owner WORKERS•COMPENSATION DECLARATION I hereby affirm that l have acertraele of consent to self-imum,or a ccmricme of Workers'Compensation)ruumnce,or a cord Gid copy thereof(Sec.3810. Lab.C). Esp.Dares Canape ❑Cann l copy a Mrmy fumineusl 17 Cenifrc lcopy is filed with the County Building Inspection Div).inn CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This action need not be completed,if the permit is for one hundred dollars IS 100)or less) I ccnify that in the pedormame of the work for which this permit is issued.I shall not employ any person in any manor an us to become subject In the Work..'Compcnsmian laws of California - Date Applicant NOTICE TO APPLICANT;If,after undrig this CcdiBemc of E canpnlun,you should became sebject to the Warkeri Ca urnmeation provisions of IM Labor C«lc.you must famthwith<arrply witM1 rvch pravisivas or this permir atoll be dccmod avakcd. CONSTRUCTION LENDING AGENCY I hereby nf&m that the.is a comtmgioa lending agency far the performance of Ne work for which this permit is issued(Sce.3097,Civ.C). Lenders Name Lendcr'n Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑I hereby certify that no excavation five(5)or mom feet in depth into which a person Is required to deste will M m ke in connasion with k work .ut,mined by the permit,and that as building somel......Roldiii ,faluwok,or demolition or dlsmanhng thereof.will M rncre than rhiny- orfm high. (Chop.3.3,Grp 2,An 2.Sec 341,Title 8,C.n.C.). Cl As awxr-builda,l will not employ anyone a do work which would require a Permit from tM Division of Industrial Safay,as noted above,on lees such person bas.permit to do such work from the divisian. ❑Division of Indasttial Permit No. I ecnify that I have read this application and sate that the above information is correct.Lagmx ro comply with all aiq•mrd county ordinonecs anJ au¢lasers relating In well cons"edon and m savage system construction,and hereby autlmrixn repraemadwssi ofthis county to enter upon llicaboya-mainional Property for iminunion purposes. Dam Applicam y k'