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I 1 If� JOB ADDRESS: PERMIT M: LICENSED CONTRACTORS DECLARATION 1 herebyaR.,rm tha I am huaaM undue the pi win as of C,Wu 9lcanmsncmg with Session 70007 of Di isim 3 M the Bosm,a rind Pief..Code. aM my liceme u er full fora and effm. License A_ txp.dte Dale Cwnrxrrr OWNER-BUILDER DECIARATION ` I hcaeby of nn Thar lam exempt from d¢Comranar's license law for she following reason(Sec.7031.5.Busnrs+and Pmfessbn.Code:Anyaq•or county wfikh rupirec a permit m comas a situ.inpmve.demolish.re a. v any itmusee.prior to its isamooe,also rc{uirm the applic'am for such permit so 01.a signed swenea thath is lkasul Pursuam so dse prm'ishsns of tlw Cmlraermi livase Law(C71sptu9(cammustmi;with Sztiun 711001 Of 1 Zisfun 3 of the Business and Professions thu Code)or at W tacmp hwefram still the bats for the alleged exemption. Any viola an of Seeder.71131.5 by ,ghplkam for•partut sabjaa me Spplkam to a avil parially of arc mO:e then frit hlutdled dolls s(S5W I): 01.m owner M the property,or ley employees with wages as their sok mmpersation,will do The work,riM she smnnse is no,IMerdcei Or offered It,sal � (Sec.7044.Busimu end Pmfe sioes Calc:The Cowrxc a Lwems law tioa as o,,ply in an owner or prapcny who hunts IX impmvsa thereon,and wim does sscb wmk hieselfathrough his uwm enpluym,Wmidcd that Safi impmvema,are seaimendMm offered fmsals• IChowever,thebmleingor irrprosti:mem is std within one yarof cony lethm,the Ounce buileler will have she borden Of pmo mfr thJ:ss did satbuild Or mplovc for the porpm Of �. We.) O I.a owner o[the prOpaty,am rxclusively coruraavhg with lions_-1 ennuriclma lanlm[lal the prujcn fSec.tt144.Bmines+ad Profession Code:The t 4 Cuis Beast Law lose nn apply m a wo(pmperry who butdv a imprwrs tlherton,aOd who canssxu fa such pmjats with s amnctMs7 yI licemset!punusnt ro tM C ¢w's Lica"Law.) 111 am exempt ualer Sm. B&P.C.fa:his reason DW WORKERS'CONIPENSATION DECLARATION I better affirm Out I have a ecnhficse ofanavu to self+mme us W30a1,M WmYen'Camp4nseuoolmwmna,Or cenifiNcopy Iheraf Mee.38W. Lab.C). Esp.Date ._Company -- O Ceaifled airy is hereby furnished ' h O CertifN copy is filed with the Cehmty BJlding lmpatias Divi um CERTIFICATE OP EXU"110N FROM WORKERS'COMPENSATION LNSURANCE - (Ties seciiou trod tta ha umplewd.if the permit Is her oro buMrsd doll.,.($10017 or less) I oatify ft,in the Mfomem.ol the work for which this permil it isvaN.I shell m emplm my person in ay mvina m as 1.bumrst subjat 1n Iso I Workers'Compmaosoo laws Of Cauctraiw Date Applicant NOTICE TO APPLICANT.If.ahn making this Curifkae of P.vcrlgm.m you should biome wbiv m'be Workers'C mi ertWion Pmviiirm ofsba Labor Cale)mmusfaN con lywithsxhpmehsimsorthh,@ml;t shallbeGemedrevokrd- CONSTRCCTIONLENDINGAGENCY Meme,aff m tha that u.eemal Wia landing agary fee to Mr..a tlls work fa which tea permit is ii sew d(Se,c.31)97,Ci,C) Isedu's No. LeMcr's Address ___ -- DIVISION OF INDUSTRIAL.SAFETY PERMIT CERTIFICATION: O 1 bumby terrify that no exe4vaioe Ove(5)W more fen in de sh iriv which spawn is mquirM so dcsxM.roll be rmhe in conncninn with work atnhonre l by ft Minn.and than m huildinS sratore,uxBolding.falsewmsk.of demnlitlm Or dismsnllinp thucaf.will be mrim then thirty six(36)(cur high. (CAap.3.2,Gp3.A.mi Sm341.Tbk S,CA.CI. ❑bpwna lnildn-1 willva enrpinY rinYoxmm wah wldrb wailer aydm•pamlfrom she Orvisian of hWusliril5¢feY-tit rotor above.unks avcM1 Pelson ha a pomit m do soeh weM from the dl.xsmot ❑Division Of foduaisl Permit No, i I mtfy teas I:uve red tles apfdkauon ail rsam IhJ Iles Jove m4ornsuhm uconm-1 agree ro comply wN all city aM comrry odimac aM ssuc kws rNating m well mmwnion end u scwaAe sysmlr camownsian and IhucNy amhaim reprtaemdves of Ibis aty to cora upon to hhbave�memiarcd pmpaty for Wires!.WNoss. Doc- App0eanl _ _