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]OB ADDIa`Sx:. - - PERrr ai #:
<br /> - ;;� 7
<br /> LICENSED CONTRACTORSDECLAR�7 N
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divis m 314ttie Busmeas
<br /> and Professions Code and my liceau`is in fid!force sod effect. s -
<br /> � CJf-)--s �a1 Js(�✓• J t-L" �7�-ifs•
<br /> —License#r . n-. Expiratloo Date A
<br /> `Date _ r 'Conmaemr
<br /> •,, _yew =ys�r„ OWNER-BUIIAER 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 ismance,.also requires,the applicant.for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor'sLicense,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 vt tion of Section 7031.5 by my appllcent for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> O I,as owner of the property,or my employoes_-it wages as their so]e.e'o'mpensatioq will tinthework.and the structureis not,/
<br /> ? intended or offered for sale(Section 7044,Business and Professions Code:The conmacor's License law does not apply to an
<br /> Yn owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> such i nl3rovements are net intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> Cls completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> J� O 1,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 contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> -..f, �. t
<br /> 0' O 1 am exempt under Section , tRAPC 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 cemfied
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certifiedcopy is hereby famished .. .
<br /> O Certified copy is filed with the Environmental Health Deppntment t r•� / s t. /
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars 3100)or less)
<br /> I 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 b
<br /> becorrr 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 /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name - -
<br /> Lender'Address -
<br /> DMSION OFINDUSTRIAL SAFETY PERMITCERTICATION�,
<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 permit,and that no building structure,scaffolding;falsework,or demolition or dismantling,"
<br /> ' 'thereof,will be more than -six 3 feet
<br /> thirty ( � high.(Chapter 3.2,Group 2,Article 2,Section'341;Title 8,California Administrative
<br /> Code):. . .. `.
<br /> { O As owney-builder,1 will not employ anyone m do worklwhich�woukt require a pertnrit-from•We,Dfi6on of industrial Safety,as
<br /> t I s noted above,unless such person bas a permit to do such work from the division.
<br /> O Division of Industrial Safety Permit#
<br /> I nertify'thnt I have read thea applicatio`u and shtethat'the above infoiination is correct I'agree to comply sntbellcity and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and bereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes. c
<br /> Date Applicant
<br /> EHD4M2-00] CONIR CTORS DECI.tRAT10N
<br /> 12/1112002
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