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i <br /> JOB ADDRESS: PERMIT R: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I um licensed ander the provisions of Chapter Y(commencing with Section 71100)of Division 3 of the Business and Professions Cade, ' <br /> and my license is in full fame and effect. <br /> I <br /> LieenseN Ez Dau <br /> I p" <br /> Dau Comraaor <br /> OWNER-BUILDER DECLARATION <br /> 1 hereby affirm that I am exempt from the Contractors License Law for the following reason(Sec.7071.5.Business and Professions Code; Any city or <br /> county which requires a permit a construct,alma improve,demolish,or repair any s0acturs,Prior to its issuance,also reouiree the applicant for such Permit <br /> to file a signed statement hat he is licensed puraumn to the provisions of the Contractor's License law(Chapter 9(commencing with Section 70(10)of <br /> Division 3 of the Business and Professions Code)fir that he is exempt herefrnm and the basis for the alleged exemption. Any1iolntionafS"tion7031.5hy <br /> any applicant fora permit subjects the applicant to.civil penal,.admit more than five hundreddollars fS500)): <br /> O 1,as owner of the propeny,or my employ".,with wages as their sole compensation,will do the work,and the structure is not tnlended orofferetl far sole <br /> (Seo-7044,13taximss and Professions Code:The Contractor's License Law does not apply to an Owner of propeny who builds or improves thereon.antl who <br /> does such work himself or through his own employees,provided that xuch improvements are not intended or uAsurd for sale. If,however,the building or <br /> Improvement is sold within one year of completion,dee owner-buildcr will have the burden of proving that he did not build in improve for the purpose of <br /> sale.) <br /> 111,as conic of the property,am exclusively enunciating with licensed contractors to construct the prow(See 7044.Business and Profession Code:The <br /> Cmao'cur's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s) <br /> licensed pursuant to the Cennerc or's License LBW.) <br /> ❑f am exempt tinder S". ,B&P.C.for this reason <br /> iData Owner <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm that I have a certificate of mnsem to self-insu¢,or a certificate of Workers'Compensation Insurance,or u carolled copy thereof(S".3818). <br /> Lab.L'). <br /> Exp.Data .Company - <br /> ❑Certified copy is hereby famished <br /> ❑Certified copy is tiled with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE: <br /> (This section n"it net be enmpleted.if the permit is for one hundred doll.(8100)or less) <br /> 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become sobj"t rot he <br /> Workers'Compensation Laws of California. <br /> Darc_,_Applicant <br /> NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should beconc subject in the Workers'Compensation provisions of the <br /> Lawn 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 strawy for the performance of the work for which this permit is issued(See.3097,Civ.Q. <br /> Lendei s Name <br /> tender's Address _ <br /> DIVISION OF INDUSTRIAL SA FETY PERMIT CERTIFICATION: <br /> ❑i herehy certify that no and <br /> thin a.five in)or more feet in depth into which a person is required to da"fid,will bemake, conn"lion i,sith work <br /> euthoriced by the permit.uN the ria building swtwre,scaffolding[eluwork,or demolition or dismantling thercoL well be more than IM1iny-six(36)(cel <br /> high.(Chap.3.2.Grp 2,An 2,Ser 341.Title S.C.A.C.). <br /> 13 As owner.buildcr.I will not employ anyone In do work which would require u permit from the Division of Industrial Safety,as armed above,onlcas such <br /> peen has u permit to do such work from the division. <br /> O Division of Industrial Permit No. <br /> I unify that I have read his application and ,.In that the above information is cor"t. 1 agree to comply with all city and county ordinances and state laws <br /> - relating to well comarnamst and ur sewage system corstruuion,ami hereby amlwriac"presenmtives of this city to enter upon the above-mentioned Property <br /> for iaspwtinn purposes. <br /> .�Dee_ APPIi<am _ — <br />