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i JOB ADDRESS: PERMIT R: LICENSED CONTRACTORS DECLARATION 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, ' and my license is in full fame and effect. I LieenseN Ez Dau I p" Dau Comraaor OWNER-BUILDER DECLARATION 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 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 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 Division 3 of the Business and Professions Code)fir that he is exempt herefrnm and the basis for the alleged exemption. Any1iolntionafS"tion7031.5hy any applicant fora permit subjects the applicant to.civil penal,.admit more than five hundreddollars fS500)): 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 (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 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 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 sale.) 111,as conic of the property,am exclusively enunciating with licensed contractors to construct the prow(See 7044.Business and Profession Code:The 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) licensed pursuant to the Cennerc or's License LBW.) ❑f am exempt tinder S". ,B&P.C.for this reason iData Owner WORKERS'COMPENSATION DECLARATION 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). Lab.L'). Exp.Data .Company - ❑Certified copy is hereby famished ❑Certified copy is tiled with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE: (This section n"it net be enmpleted.if the permit is for one hundred doll.(8100)or less) 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 Workers'Compensation Laws of California. Darc_,_Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should beconc subject in the Workers'Compensation provisions of the Lawn Code,you must forthwith comply with such provisions or this permit shall be,deemed revoked. CONSTRUCTION LENDING AGENCY 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. Lendei s Name tender's Address _ DIVISION OF INDUSTRIAL SA FETY PERMIT CERTIFICATION: ❑i herehy certify that no and 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 euthoriced by the permit.uN the ria building swtwre,scaffolding[eluwork,or demolition or dismantling thercoL well be more than IM1iny-six(36)(cel high.(Chap.3.2.Grp 2,An 2,Ser 341.Title S.C.A.C.). 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 peen has u permit to do such work from the division. O Division of Industrial Permit No. 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 - relating to well comarnamst and ur sewage system corstruuion,ami hereby amlwriac"presenmtives of this city to enter upon the above-mentioned Property for iaspwtinn purposes. .�Dee_ APPIi<am _ —