|
• -::,�:r.:.--�r.[.�..W of?n._».:.- -.._.... ..,...--.'. +..: .-- ... ...w.v S!�"
<br /> 1
<br /> JOB ADDRESS' PERMIT#'
<br /> -_ LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby.affmn�bat I am licersedunder the provisions of Chapter 9(commrncmg�wrth Swtion 700)of Division Sof the Business
<br /> _-aired Professions Code and-my' license is in full force and effect. g �'-
<br /> License#; Expiratlrn Date-,l<\ ��•\�
<br /> Date r':\ \ � Contractor t\tit
<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 v'I Scction 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 more than five hundred dollars($500)):
<br /> 0 I, as owner of the property, or my employees with wages as their sole compensation,will do the work and the structure is-not1
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner.
<br /> of property who builds or improves thereon,and who does such work himself or through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If,however,the building or improvement is sold within one yew of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> 0 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 /> 0 lam 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 /> O Certified copy is hereby furnished
<br /> 0 Certified copy is filed with the Environmental Health Department
<br /> 1 CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be comoleted if the nednit is for one hundred dollars($100)or less) - ` u
<br /> I certify that in the performance of the work for winch this permit is issued,I shall not employ any person in any manner so as to
<br /> become subject to the Workers'Compensation laws of California.
<br /> Date: Applicant
<br /> t 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 forthwftli comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTR13(I OMLENDING AGENCY l
<br /> I hereby affrm�re js a construction lending agency for the perfo)rtnancc of the work for which this permit is issued(Section
<br /> 3097,Civil Code). 1
<br /> i
<br /> Lender's Na'me�
<br /> _
<br /> _I.ender_Address..
<br /> --------------
<br /> DMSION 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 8,California Administrative
<br /> Code).
<br /> r u _
<br /> 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,M
<br /> noted above,unless such person bas a permit to do such work from the division. `
<br /> ❑Division of Industrial Safety Permit# _
<br /> I certify that I have read this application and state that the above information is correct. I agree to comply with all city and cmmty
<br /> ordinances and state laws relating•to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes. -
<br /> Date Applicant
<br /> EHD 43-02-007 - - _ 12/23/2001
<br /> Water Well Permit CmtrwWr Dwlaracdm 4-02
<br />
|