|
JOE ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License#_ Expiration Date
<br /> I' Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> i hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that be
<br /> f is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> ❑1,as owner of the property, or my employees with wages as their sole compensation,will do the work,and the structure is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's Lice:tse Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through hie own employees, provided that such
<br /> improvements are not intended or offered for sale, If,however,the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden ofproving that he did act build or improve for the purpose of sale.)
<br /> O I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑I am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> 13 Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100)or less)
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any maturer so as to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you. should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> k Lender'Address
<br /> f,
<br /> C DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ I hereby certify that no'excavation five(5) or more feet in depth into which a person is required to descend, will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding, falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3,2,Group 2,Article 2,Section 341,Title$,California Administrative I
<br /> Code):
<br /> i
<br /> E3 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as
<br /> I noted above,unless such person has a permit to do such work from the division.
<br /> 13 Division of Industrial Safetx Permit
<br /> I certify that I have read this application and state that the above irrfbiataiiou is'dorreciagree to comply with all city and county
<br /> ordilt-mces and state laws relating to well construction and or sewage system IFOM r'ut:tionk d hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection putpo§es: • r.yar..s•
<br /> F
<br /> Date Applicant
<br /> EHD 43-02-007
<br /> water Well Permit Conkacuw Declaraction 4•o2 t2h3r2003
<br /> 3
<br /> i
<br />
|