|
JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION '
<br /> I hereby affirm that 1 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 s,
<br /> Date Contractor
<br /> 'n OWNER-BUILDER DECLARATION -
<br /> �. 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following mason (Section 7031.5, Business and
<br /> VProfessions Code: Any city orcounty which requires a permit to construct,alter,improve,demolish,or repair any structure,prior in
<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 he
<br /> 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 mom than five hundred dollars($500)):
<br /> ❑ I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure is not
<br /> �) intended or offeredfor sale(Section 7044, Business and Professions Code:The contractor's License Law does not apply to an
<br /> i, owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> i such improvements are not intended or offered for sale. If, however,the building or improvement is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose ofsale.)
<br /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a contractors)licensed pursuant to the Contractor's License Law.)
<br /> O I am exempt under Section. ,. B&PC for this reason
<br /> Date; Owner
<br /> WORKERS'COMPENSATION DECLARATION '
<br /> I hereby affirm that I have a certificate4consent to self-insure,or a certificate of Workers'Compensation_Insurance,or a certified
<br /> copy thereof(Section 3800,Labor Code). _
<br /> Expiration Date - Compaby
<br /> O Certified copy is hereby furnished I -
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS]COMPENSATION INSURANCE
<br /> (This section need not be completed-if theeermit'is for one huui dred-dbllars'f$f dol-wlcssi J
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ arty person in any miner so as to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> 'Date. Applicant '
<br /> NOTICE TO APPLICANT: If, after 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 /> .1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is isl'(Section
<br /> 3097,Civil Code).
<br /> r,
<br /> Leader's Name
<br /> Lender'Address
<br /> ' DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 'O 1 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 parmiq-and Nat no building stricture,scaffolding,-falsework,or demolition or dismantling -
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Croup 2,Article,2,Section.341,Tide 8,California Administrative
<br /> O As owner-builder,I will not employ anyone to do work which would require a Omit from the Division.of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such workfrom the divisions] -
<br /> ❑Division of Industrial Safety Permit#
<br /> ,V.
<br /> I certify that I have read this application and state thal.the above information iscorrectagree N�itiply wit _all 6ity':and county
<br /> ordinances and state laws relating to well construction and or.sewage.system construction,:and hereby aathorizeropmaentatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> -Date °' Applicant
<br /> EHD 43-01-007 LICENSED CONTRACTORS DECLARATION
<br /> '171112007
<br />
|