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JOB ADDRESS: PERMIT Y: LICENSED CONTRACTORS DECLARATION I hereby affirm drat l am beensd under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of die Business and Professions Code. and my license is in full force and effect. LicnueN_ E.,Mia Date Cpmacim OWNER-BUR,DER DECLARATION I herby affirm that 1 am exempt from the Contractors Wcense Law for the following reason(Sec.7031.5.Business ad profcsticun Code; Any city or county which requires a pmmh to construct,after.improve,demolisls or repair any structure.prior to Its)w umce,also require.the applici m far suet,permit m)file a signed stmersern that M is licensed pursuant m the provisions of the Cmuacmh License hon(Chapter 9(commencing with Section 7000)of Division 3 of the eusincss and Professions Cede)ex that M is exempt lun f,m and the basis f.c he alleged exemption. Any violation of Scanlon 7031.5 by anyapplicintfor a permit subjects the applicant to asdvil pe®Imy ofnnt mom than five hundreddollen ($500)): O 1,ss ewrcr of the property,m my cmployces with wage¢u dreir sole<ompe....ion,will dote work,and me structure is nor intendedoeoffered fa agile (Sec.7M4,Business and ProfesuonsCdc:The Common,t LicenseLaw does not apply to an owner of propraty who builds m improves thereon,and who does such work himself m through his own employees,provided that such improvements are not intended or offered fre sale. If,however,the W ilding en improvement is sdd within aro ywr of conTldoq eche owner-builder will Mve mM burden of proving etas to did res build a impmve fm thepapose of sale.) O 1,as owner of rtne property,am exclusively commeting with Imensed contractors to construct the project(Sec.7074,Busiocu and Profession Code:The Contractor'.❑ceme Law does ria apply In an owner of property who builds or improves thereon and who contracts for such projects with a contacmer(s) licensed putauanuo in,Conmacter's Licenso Law.) 13 l am exempt under Sec. „B b.P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION I Mreby arcrm Nat IMve a certificau otcoment m self-insure.a a csni0cate of Workers'Csrrcemation Insuresmec,or a certified copy iherto[(Sec.3800, leb.Q. Exp.Dau Company O Certified copy is hereby furnished O Certified copy is filed wide the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be compleuul.if me permit is for one hundred dollars($100)in less) I certify that in she pericamana of the work for which Out permit u issued,l shall ria employ any person in any snamn,an as in become subject rot he Workers'Compensation hon.of California. Dane Applicant NOTICE TO APPLICANT.If afmr making this C:nifcwe of Exemption,you should become subject to the Workers'Compemation provisions a the ubor Code.yen must forthwith comply with such Provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm dot then,is a com riedm lending agency for me,performance of the work for which this permit is issud(Sec.3097,Civ.C). Lender's Name LeMer's Adtlrecs DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O 1 hereby certify,that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in mnoecdon with work authorized by the permit,end that no Wilding structure.sc.ffuldieg.Disew.A.o demolition or dismantling thereof,will be mor than HAY-six(M)feet high. (Chap.3.2.Gip 2,An 2.Sec 341.Title S.C.A.C.). -O As owner-builder.I will not employ anyone to do wok which would aqui,a prmtit from the Division of Industrial Safety,w noted above,unhess such person bat a permit m do such work f,m nhc division ❑Division of lM anal permit No. 1 certify ibar I have read this a"hemico ad"ate that the above information ns comer I agree to comply with all city and county ordinances risel acme laws for inspection n6 w well purposes.inn and or sewage system consimcdan,and Mreby au[horl,rep,senutivc of this city m comer upon rM eMvo-nsenuoned pmperiy far inapu:ticn pumgx¢. Dau Applicam