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i JOB ADDRESS: PERMIT K: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am bceneed under the provisions of Chapter 9(comhnencing with Section 7000)of Division 3 of We Budneas and Professions Code, and my license is in foil farce and effect. License N Exp.:Duc Usm__Concador OWNER-RUEDER DECLARATION 1 hereby affirm Nat 1 am exempt from the Contrador's Licrmc law for the following reason(Sec.7031.5,Business and Pmfrmions Code; Any city or county which requires a permit on mango l,Wer,improve,demolish,or repair any structure,prior to its issuarm.also mq,dues the apdised,fee each permit us file a signed sutemem dint heDivisis Gcena<d on 3 ofthe Business add� cena<dputsuem m the provisions of the Conuazmr's Liccnsc Law(Chapter 9(comrrcncing witfi$emion]Oo0)of ro&ssians Code)or that he is exempt hcmfmm and the basis for the alleged esemptioo. Any violatian of Section 7031.5 by any applicant For a permit mbjecb tot applicant to a civil penahy of het trots than Ove borated dollars (550(1)): ❑1,as owner of Ne progeny,or my employees with wages es their sole wmpe...tlon,will do the work,and the stmcmre is not intended m offered far.1. (Sec,7044.Business and laofessdmn Cad.::The(Dern acloi s License Law does not apply to an..or of property who builds or improves thereon,and who aces such work himself ca through his own employes,provided that such improv.nod ItM arc not intended a nfkoed for sale. If,however,the building or impmvemcnt is sold within one year of ocrup)uin t,the owner-builder will have the burom of proving that be did not build or improve for the purpose of sale.) ❑1,as Owren of the property,am exclusively contracting with licensed contractors to construct the project(SeeJW4.Business and Profession Code:The Contractors License Lw does not apply to an owner of property who builds or improves thereon,and who commit for such projects with a mnuncte(s) hosmed pursuant an the Contractor's Luu me LawJ ❑I am eacmpt under Sec. ,B A P.C.fur Nis leaaott _ Dam Owns, WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to mV-insure.e a certificate of Worker Compensation Insurance,or a cer6fed copy thereof(Sec.3W, Lab.C)- Esp.Date Company ❑Cenified copy is hereby fumishN ❑Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS-COMPENSATION INSURANCE (This section nred net be completed,if red permit is for one hundred dollar.($IDo)or less) 1 certify that in ted performance of the work for which this permit in issued,I shall Om employ any person in any manner ao as 1.become subject lot he Workers Compensation laws of California. Date.___,_Applicant NOTICE TO APPLICANT;if after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions ofshe labor Code you must forthwith comply with such provisions or that pemtir shall he deemed mvoked CONSTRUCTION LENDING AGENCY 1 hereby affirm that these is a construction lending agmey for In,pertormancc of the work for which this permit is issued(See.3097.Civ.Q. Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑1 haaby scnify the,do excav&ion five(5)or mord feet in depth into which a person is required m demesd.will be make in connection with work authorized by the permit,and that no building sWcture•scaffolding,folmwork,Or demolition or dismantling thereof,will be onre than thirty-six(36)feet high. (Chap.3.2,Grp 2.Art 2.Sec 341.Title g.C.A.C.). ❑As owner-hailder,i wilt not employ anyone to do weals which would rectum a permit from the Division of ledustrial Safety.as noted above,unless such person has a permit to do such work from the division. 13 Division orindustrial Permit No. I arty that 19eve read tris application and able that the above int tion is roman. I agree m comply with all city and county oNinanas and slue laws �� relating ro well co nand or sewage synem wnstmnion,antl hereby authors rtpmscnutivcz o(tids city to enter upon the above-trcrtioned property t for inspection purposes. 1 Dale- _APPlicant._ _