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ti ' Joe ADDRESS: �d 3log_[_�.,{I 4 U�}l Ys'l/_ __.. __ PERMIT II: ' LICENSED CONTRACTORS DECLARATION 1 1 hereby affirm that I am licensed under the provisions of Chapter 9(c0mmenang with Section 7000)of Division 3 0(the Business and PrMesslOns Code and my license is in full force and enea License# 10 5 Expiration Date (3 Date � b contractor, 1/IGt.fAA.IW i OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law mr the following reason(Semon 7031 5 8uslress and Professions Cade. Any city or county which requires a permit to construct. alter.improve.demohSh,or repair any structure, on,( to its issuance -amo requires the apprcanl for such permit to(icea signed vaiemern ,,at lie is scensed Pi✓SOam to If, provisions of the Contractors iLicense Law(Chapter 9 (Commencing wtm Section 7000)0(Division 3 of the Buamess and Professions Code) or that he Is exempt herefrom and the basis for the alleged exemption Any violation of Section 1031 5 by any applicant for a perms subjects the apphcanl to a awl penalty of not-ore than five hundred dollars(55001) O I,as Owner Of the property Or my QmpiOYees with wages d5(heir sole cOmpensdtiDn well tl0 the work end the siruclure is not intended or offered for sale (Section 1044, Business and Professions Cape The eonitactOr's License Law does no!apply to an owner of property who builds or improves thereon and who does such work himself Of thraugh his Own employees. provided trial such improvements are not intended or offered lot sale if however me budding of Impmvemeni s ,to within one year of ' completion,the owner-budder will have the burden of proving Iha'l he din not bui10 of improve lo(the purpose of sate i 1 O 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and ProWsi0n5 Code(06PC) The Contractor's License Law does Iii aPP1y to an owner nl pf0gPAy who builds a Improves hereon, and who constructs for such projects"in a COOIrachor(sl licensed pursuant to the COnlraCtOr'S License Law I ' O 1 am exempt under Section B6Pe far this reason Date: Owner: ' WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a Certificate Of consent 10 Sell insure or a Cedificale of Workers'COmpenSalion Insurance.or a '. Certified copy thereof(Section 3800.Labor Code) -- — Expiration Date Company._ —LL- — ❑Certified copy is hereby furnished ' I O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed It the oermil Is for One hundred collars($100)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 SO as to become sublecl 10(tie WorkersCompensation Laws of California Date: _-- APphcanl_—"_-- ___-- _._. NOTICE TO APPLICANT u, after making Ihrs Certificate of Exemption. you stroul0 become sub)ed to me Workers' Compensation provisions of the Labor Code you must forthwith comply with such provisions or this permit shall be deemed revoked ICONSTRUCTION LENDING AGENCY I hereby affirm thal there IS a Construction lending agency[of the performance Of the work for which this permit is issued (Section 3097.Civil Code) Lenders Name _ ' Lender Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby Certify that no excavation five (5) of more feet in depth into which a person 1s required 10 descend, will be made in connection with work authorized by the permit,and that no budding strpaure scaffotoing. falsewOrk of demohoon of dismantling thereof,will be more then mvtysix (36) feel high (Crispier 3 2,Group 2 Article 2 Section 341 file tl. California Administrative Code) O As owner-builder. f will not employ anyone to do work which would require a permit corn the Division of Industrial Safety,as noted above. ,,less soon persol.has a oa mit ib do such.11,ft.'the mvrsron O Division of industrial Safety Permit As 1 Part that I have read this application and stale that me above information is correct 1 agree to comply with an city and county ordinances and slate laws relating to well construction and or sewage system construction,and hereby av Npr¢e mphi sentalwi s of this county to enter upon the above-memion20 property,for inspection Purposes Date Applicant If' I ' EMD(YOT LICENSED CONTRACTOR OECURATION