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} .106ADDRcSS: I I.� ��!SUr� RA 5 ! •'� PEI2KST LICENSED CONTRACTORS DECLARATION I herety arm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Prcf ss4ons Code and my license is in fcull force and effecL License Expiration Data Date Contractor OWNER-BUILDERDECLARATION I hers-by affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions Codec 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 far such pemnit to file a signed statement that he is licensed pursuant to the provisions of the Contactors License Law(Chapter 9(oon7mercirig with Section 7000)of Derision 3 of the Business and professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a evil penalty of not more than five hundred dofiars(5500}} Q 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for safe(Section 7044,Bustrhess and Professions Code:The contractor's License Law does not apply to an -timer of property who builds or improves ttherecn,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sa3e.'if, however,the building or irnprovemant is sold within one year of completion,the owner builder-Mll have the burden of proving chat he did not build or improve for the purpose of sale.) ❑i;as owner of the property,am exclusively con6actimg WVi licensed contractors to construct the project(Section 7044,Business and Professions Code(WC): The Cantractoes License Law does not apply to an owner of property who builds or improves hereon, and who oonsfitzis for such projects with a co-itractor(s)licensed pursuarrtto the Contractor's License Law_) 01 ami exempt under Section , B&PC for this reason Data: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of ransentto self-insure ora certificate cf Workers'Compensation Insurance,ora certified copy thereof(Section 3800,Labor Code). Expiration Date Company ❑Certtifed copy is hereby fumished ❑Certified copy is filed wifn the Environmental Health Departrnent CERTIFICATE OF EXEMPTION FROM WORKERS'COWL}ENSATION INSURANCE fTnfs seAton need not be completed if the oermh is for one-hundred dollars($1005 or less) I cer*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 subject to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT:If,after making this Certftcats of Exemption,you should become subject to the Woriars'Compensation provisions of the Labor Cade,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the pec,onnance of the work for which this permit is issued(Section 3097, Civil Coda). L.endoes Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five(5)or more feel in depth into which a person is required to descend,will be made in connection with work authorized by the permit,and that no building structure.sc,anelding,falsework,or demolition or dismiantling thereof,will be more than thirty-six(38)feet high_(Chapter 32,Group P,Article 2,Section 341,Tale 8,California Admintsirative Code). M 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. ❑Division of Industrial Safety Perini# I carfify that 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 refacing to welt construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-neritioned property for inspection purposes. Date Applicant EHD4302-Wr LICENSED CONTRACTORS"DECLARATION 52609