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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License# Expiration Date Date Contractor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner of property who builds or improves thereon, and rwho does such work himself or through his awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project(Section 7044, Business and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) ❑ I am exempt under Section B&PC for this reason Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers' Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company ❑ Certified copy is hereby furnished 0 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE t• r (This ser-tion.need not he nmmnletPr3 if tha narmit is fnr nnr hnnrlrarl dMinre(T 1 nn)nr 1P 1 I �OOZILIS { Ilwll3d TUM 113IVM IMsvw 9D0 ZO-£4 aHd !Tv 40 reVium.-V �. �S L #lsan aH aalAaaS g awaH o;ul sapo�#a111am #aalonu[ 11iwlad paAlaaaHn �S 3d �j G►ob�} >aiNi�ncs 4-Zz"' S-LNSYHINO� l; Nlda(I 11aM palanilsuoi a1s Q Ag uo+laadsul uopon]1saa paAlaaaa H3AIVM I] Ag uoilaadsul dumd alulaad 11aM"IV133dS ❑ :)1 CC[ Aa uopwdsul inoirj #Q1 aaXoldwg - eauv o o1vu �8 Paldaaoy uonsa�lddy