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JOBADDRESS: L7/f�� a� � PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that l em licensed under the provisions of Chapter 9(commending with Section 70o0)of Division 3 of the Business and Professions Code and jmy license is in full force and effect 1-1001130# pp3 Expiration Date if%A� Date_ 2p. /3 Contractor rawrale; amp OWNER-BUILDER DECLARATION I hereby affirm Nal I am exempt from the Contractor'a License Law for the coovdng reason(Section 7031 5.Business and Professions Cyte: Any city of county which requires a admit!10 constructaIle, nllprove.demolish,or repair any structure,prior To Is issuance, also requires the applicant for such permit to file a signed statement that hers licensed pursuant to Ne provisions of The Contractor's Licause Law(Chaplet 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that hen exera l hereffom and the basis Iy the alleged exemption Any vldallon of Section i031 5 by any appbcam for a permit subjects the applicant W a civil penalty of not more than five hundred dollars(E500)) Cl 1,as owner of the property. or my employees with wages as thea sole compensation. will do the work and The structure is 1101 intended or offered for sale (Section 7044, Business am Professions Code The Contractor's License Lew aces not apply to an owner of property who builds or Improves thereon and who does such work himself or through his own employees,provided had Rich improvements are not intended o, offered for sale It however the budmng or improvement is sold within one year of compilation,the owner-builder will have the burden of Moving Nat he did not Wild m improve for the pose of sate 1 ❑1,as owner or the property,am exclusively contracting with licensed contractors to Construct Ins pro)ect(Section 7044,Business and Proleseiens Code(Ba PC) The Contractors License Law does not apply to an owner of property who builds oT Improves hereon, and Who cansti for such projects with a conlector(s)licensed pursuant to the Contractors License Law) O l amexampf under Section __, B&PCfOadsstea5On _— ____—____. Date: Owner. WORKERS'COMPENSATION DECLARATION -.I hereby affirm that 1 have a certificate of consent 10 self-insure ora certificate of Workers'Compensation Insurance.ora certified copy thereof(Section 3800.Le - Expiration Date Company ❑Cerfifed copy is hereby furnished O Certified copy Is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (Thes section need not be combteted if the oermd 15 for one hundred dollars($1001 or less) I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person in any manner s0 as to become subject to the Workers'Compensation Laws of California Date, Applicant NOTICE TO APPLICANT'. It, after making this Cemficate of Exemption.you should become subject to the Workers'Compensaton provisions of the Labor 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 agency for the performance of the work for which this permit is issued (Section 3097.Civil Code) Lender's Name Lender'Addrass DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION I hereby certify that no excavation flue (5) or more lest n depth into which a person Is required to descend, will be made in opnnedion with wolf authorized by the permit,and that no Wading structure. scaffolding. falsework or demohbon or anmant nal - lhereol,will be more then thirty-six(361 feet high (Chapter 3 2.Group 2 Anicta 2 Section 341. Title 8. California Administill Code) 0 As pNTehb nWer,1 wdl not employ anyone to do work which vWNd require a oarmil from the Division of Industrial Safety,as rbNd abow, unless such person has a permit to do such work from.the division CI Division of Industrial Safety Permit# I partly Nat I have read this application aha state mat me above information is correct 1 agree to comply win an oty and county urtanenoas am steaws le lreading to well consWclxxt am or sewage system moslrudlon,and hereby authorize representatives of this county to enter upon Uro abov6-mentioned property for Inspection Mu poses Date Applicant i shot", LICENSED Ccerflb CTOR EXCIARATION