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JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTOR&DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License#, Expiration Date, 1
<br /> Date Contractor i
<br /> OWNER-BUILDER DECLARATION
<br /> / 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which,requires a'permit to construct,alter,improve,demolish,or repair any structure,'prior to
<br /> its issuance,also iequires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and theUasis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> - ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> 2 intended or offered for sale(Section 7044, Business and Professions Code: The contractor's License Law does not apply to an
<br /> i owner of property who builds orimproves thereon,and who does such work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> . .
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> 7
<br /> i ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property-who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> i ❑1 am exempt under Section B&PC for this reason
<br /> Date: I t Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate''ofconsent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified.copy is'filed with the Environmental Health.Department ;
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100)or less)
<br /> 1 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
<br /> become subject to the Workers'Compensation Laws of California. 1 y
<br /> Date: Applicant l 1
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you,should-become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY-"-
<br /> I hereby affirm that there is a construction lending agency for the performance of the Ark for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> i
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ I hereby certify that no excavation five(5) or more feet in depth into which a person is required to descend, will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition-or dismantling——"
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,-California Administrative
<br /> ❑As owner-builder, I will not employ anyone to do work Whichwould require a.permit-from.the.Divis_ion of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> I'certify that I,have read'this application and state that the above info�ation'is`correct:'I agree to comply-with all city and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and herebyauthorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant- it
<br /> EHD 43-02-007 - LICENSED CONTRACTORS DECLARATION -
<br /> 12/1112002 -
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