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JOB ADDRESS: PERMIT A: LICENSED CONTRACTORS DECLARATION I hereby affirm that l am licensed umkr the provisions of CTapter9(mmnuncing with Section 7000)of Division 3 of the Business and Profusions Code, and my liter.is in fall force and effect. Llmnse a_ Exp.:Dme Date Contractor -, OWNER-BUILDER DECLARATION 1 herMv affirm that 1 am exempt from the Cantractm's 6lceme Law for the following mouth(Sec.7131.5,Business and Prolasdom Code; Any dry m county which seyuires a Permit!a conswea alter,improve,demolish.us r.pm any swctum,prier m its issuance,also requires the appllearn for such permit an file a signed rammed thus he is licensed pursuant to the provisions of the Contmclei s Uccuc Law IChapler 9(cdmmxncing with Sections 7(100)or Division 3 of the Business and Proiesdnns CeMc)m tFvt he H exempt Fercfmm pod she basis fm drc alleged exemp0on. Any vi.1mon of Sec i.7031.5 by any applicant for•permit subjects the applicant w a civil Pendry o(nat more Ihen five hundred dollars(SSfq)): ' ❑1..owner M the properly,ce my empinyec with wage,as the¢rule eumourn tian,will do the work,and the structure is am intended areffered for sale (Sec.7W4.Hudnua and Aofcmiom Cude:The Convectors 1.ken.Lmr Jtas ma apply to an nwnmM prapnry who builds err impmvthereon, who docs sueh wmk himself or through hix own,:mployet provided that such impmvemenB ate rat intrntlN th offered for role.1f,huwe r.the buildingi.g improvement is sold within one year Mcompinim,theeoowner-builderowner-builderwill hate the buNen of prm'ing that I•x did nm build ur imf r,prove Ion the puepox off t I seie.l ❑1,as owner M the pmpeny,amezdudve4y contracting with lian.d ennvazmn to emRmn the pmjm(Sea 7044,Business and Profession Code The Cmdumtur r Licca.Law dre not apply m on owner of peopeny who butldv pr impmvea Iheeerm,and who rmArscts for each projects with a contracvx(s) licensed faun...,active Constructor's Liena-aw.) ❑Iumeaempt under5m. ,D&P.C.[uriw r:man I Date Owner WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have..1 fires of content tu.lf-im er,or a c...ilkme of'WorkersCompensation lnsurmre,or a certified copy thereof(See.3900, Lab.Q. I i E.,Date Company - D Certified cap,is hereby Famished O Cer ified ropy is film with rhe County Building Inspersion Divisino CERTIFICATE OF EXEMPTION FROM WORKERS'COMPFslSATION INSURANCE. ('Chis section need not he completed.if the permit is fm one marked ed dollars iM(0)or less) 1 certify that in the performance of the work for which this permit is issued.l dull not employ any person in any manner so as t6 become subject wt he Workeri Competssation Laws of C.lifumiu. Dart Applkant NOTICE TO APPLICANT:If,after making this Cavifict[e of Exampurn,you should become subject m the Wohns'Compensation provuroeuaf the labor Code,you mut fanpwith comply wish such pmvismas or this pe,.at site)]be deemed revoked. CONSTRUCTION LENDING(AGENCY 1 hemlry affmm Chas ncrc is a connmction lending agency rm the perform....of the *fit for which this perma is usucd(Ser.3097,Cie.Q. Lender's Nome Lender's Add.,, DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O 1 hereby rcmfy[hat m creay.d.five(5)or marc feel in depth iron which a persons ecquired to descend,will be make to eunnexion with work :mlenii,ed by the perrrkt,and that nobuilding mruesare,scaffolding.falmvurk.ordualmAt ion he dismantling there F.will he more than Ihhty-six(36)far high.(Chep.3.2.Grp 2.Art I Sm 341.Tide S.C.A.C.). O As owner•buildm,I will nm employ anyone to do work which would rcywrc a pronir from the Division of IrMunriai Safety,as noted obswe,antro.such person Iwo.mems,m do such work from the division. O Division of lod usuml Prrmu No. I eeNfy that 1 have mad this application and a=Ihlt the above Information i...nett 1 ague to comply with alt city and mwnry'nMinences and ram laws or inspection ct wall conatrvdion aM or sewage system crosteuction,arM ha dp mnhurizc rcpmttmmivu of this siq m enter open the ubuve-menssarmd property far nspersion pugassca t Due Applicant