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Jon ADDRESS: ,✓V v fi,4//f L1 )e �' PE(UAIT IE: LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chapter 0(commencing with Section 7000)of Division 3 of Ino Business and Professions Code and my license Is In full force and effect. License II 964224 Expiration Date 08/31/2021 _ ~— Data_ / ContractorO�L j? Ct�NS7`L�G/�f0/U `J>2/2d%Gas OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Conlraclor's License Law for the following reason(Section 7031.6,Business and Professions i Code: Any city or county which requires a permit to construct.alter,Improve,demolish,or repair any structure,prof 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 Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt horofrom and the basis for the alleged exemption. Any violation of Section 7031.6 by any applicant for a permit subjects the applicant to a civil and of not more than We hundred dollars($500))! ❑I,as owner of the property,or my employees with wages as their sole compensation,will do[he work,and the structure Is not Intended or offered for sale(Section 7044, Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work himself or through Ns own employees,provided that such Improvements are not Intended or offered for sale. 11, however, the building or Improvement Is sold within one year of completion,the owner-bullder will have the burden of proving that he did not build or Improve for the purpose of sale.) ❑1,as owner of[he property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of properly who builds or improves hereon, and whoconslruc[s for such projects with n conlractor(s)licensed pursuant to the Contractors License Law.) ❑1 em exempt under Section ., B&PC for this reason Dale: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to selflnsuro or a cerilficale of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date 08/02/2020 Company State Workman's Comp Fund 9066578 ❑Certified copy Is hereby furnished to Cert holder Crawford &ASSC. ❑Certified copy Is filed with the Environmental Health Department C SSB CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE s ectlorl Red bol be complgt-el f the 2gnP(k_fgLp.o hundfQ05jo1jars(510o)or less[ I certify that In the performance of the work forwhIch[his permit Is issued,I shall not employ any person In any manner so as to become subject to the Workers'Compensallon Laws of California. Date: Applicant NOTICE TO APPLICANT:If,alter making[his Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or[his permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that[hero 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's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five(6)or more feet in depth Into which a parson Is required to descend,will be made In connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than Ihlrty-six(36)feel high.(Chapter 3.2,Group 2,Article 2,Section 341,Thle 0.California Administrative Code). ❑As ownor-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. ❑Division of Industrial Safely Permit fl I certify that I have read this application and slate that the above Information Is correct. I agree to comply with all city and county ordinances and stale taws relating to well construction and or sewage system constructlon, d hereby authorize representatives of this county to enter upon the above-mentioned property for Inspection purposes. Dale `3 —� Applicant E]ID 4307 001 LICEN6ED CONM ACTORS DECLARATION 626-00