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Joe A=Rsss:-��Io at, PERMIT#: ,, ———---------------- - LICENSED CONTRACTORS DECLARATION hereby affirm that I am"cansea under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and m Ie is dyein&II force and effect. License# Expiration0ate Date Contractor 2;e'f�, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Conitradoes.License Law for be following reason(Section 7031.5,Business and Professions Code: Any city or county which requires a permit to construct.alter,improve.demolish,or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Conbactq's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt harafrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)): 1,as owner of the property,or my employees with wages as their soia compensation,will do the work,and the structure is not intended or offered for sale ISschon 7044,Business and Professions Code:The comrscWS License Law do"not apply to an owner of property who Wkk%or improves thereon,and who do"such work lism"t or through its own employees,provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion.the owner-}wilder will have the burden of proving that he did not build or improve for the purpose of she.) E3 1,as owner of the property.am e*clusivoiy contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): The Contractor's License Law do"not apply to an owriar of property who builds or improves hereon, and who consinxis for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) 0 1 am exempt under Section B&PG for this reason Date: Owniw__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a csM,cats of Workers`Compensation IrkWpkace, a co ifill copy thereof(Section 38K,�d PA E ration Dal I.K/ company xpi 0 Certified copy is hereby tura hoc NdCeirtrflad copy is filed with the Environmental Health Department p<, CERTIFICATE OF EXEMPTION FROM WORKERS`COMPENSATION INSURANCE (This section nilled not A. ... 29Mpjetag if the. Lvir.,mit ji for one hundred dollars($192)or Lml 1 certify that in the performance of the work for which this permit is issued,I shag not employ any person in any manner so as to become subject to the Workers Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such promsions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY -(Pby affirm that there is a construction lending agency for the pertorn)axe of the work for which this permit is issued(Section 3097, Cavil Code) Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION C3 I hereby certify that no excavation five (5)or mons feat in depth Into which a parson is required to descend.will be made in connection with work authorized by the permiL and that no buIdN structure,scaffolding,fasework,or demolition or dismantling thereof,will be more then thirty-six(36)teat high (Chapter 3.2.Group 2,Artiche 2,Section 341,Tide 8,California Administrative 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as noted above.unless such person has a permit to do such work from the division. 0 Division of Industrial Safety Permit ........... I certify M I have read this application and state that the above Information is correct. I agree to comply with all city and county Ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-rrientioned property for inspection purposes. Date Applicant END 4&02-007 LICENSED CONTRACTORS DECLARATION 6-20-M