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Joh Am)RvSS: PER NI IT b: LICENSED CONTRACTORS DECLARATION I hereby affinn that I am licensed under the prolAsions of Chapter 9(corrunencing N%ith Scction 7000) of Division 3 of the Busir and Professions Codc and my license ss in full force and effect. License #_ Expiration Date Date Contractor OWNER-RtILDER DECLARATION I hereby affirm that 1 am exempt from the C'ontractor's license Law for the following reason (Sectior. 7031.5, Busin, Professions Code: Any city or county which requires a permit lu eurtsimct, alter, improve. demolish, Or repair any structure, its issuance, also requires the applicant fir such permit to lite a signod statement that Ile is licensed pursuarrt to the provision cctilrn.-Ior's I.icense Law (Charter 9 (contrnencinr. with Sr-ctior. 7000) nr Division ? of the liusiness and Professions Code)of is exempt lierefrom and the basis for the alleged exemption. Any violation of Section: 7031.5 by any applicant for a permit the applicant to a civil penalty (Snot fixne than five hunarod dollars(S500)): ❑ I, as owns of the property, o� my employees with vvages as their yule wng)rnsation, will do the work, and the struclur intended or offered for sale (Sectio) 7044, Business artd Professions Code, The contractor's license Law does not apply to at of property. who builds or improves thereon, and who does such work himself or through his owr. employacs, provided tt inrpruverrienls are not intended or offezed fur salr. 11; hwve urr, the building ur irnprovcment is sold within one, year of com the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ I, as oAmer of the property, am exelmuvely contracting, with licensed contractors to co:rstruct the pro,cct (Section 7044, E and Professions Curie(B&PC): The Contractor's License Law does not apply to an owner of property who builds or imprtwes and who constnicts for such projects with a contractors)licensed pursuant to the Contractor's License I.aw) D 1 am exempt under -,CCtiOn B&,PC'for this reason Date: Owner WORKERS'CONI VENSATION DI'C_LARA'TION I hereby ailirra that l have a"irtificate of cumirnt to self-insurt. or a omll icatc ul'Workers' Compensation Insurance,or a certi: copy Ihrroof(Sect.ien 3800,Labor Code), Expiration Date Company 0 Cettifitd copy is hrrehy lurnished L3 Cc.etitic.dcopy is filed with thr Envuunmculal 11--alth Dcpartrrunt CERTIFICATE OF EXEMPTION FROM WORKERIS' COMPENSATION INSURANCE (This section need not be cor-oleted if the permit is for one hundred dollars($100)or less I certify that in the performance of the work for wh:ch this pemvt is isstte'd, I shall not employ any person m any rnamter so as tr become subject to the Workers' Compensation Latin s of Califotma. Datc: I Applicant NOTICE TO AI'PLICA_NT: If, after making this Certificate of Exemption, you should become subject to the V Compensation provisions of the Labor Code,you must forthwith comply with such provisicns or this pctm t shall be deemed re CONSTRUCUON LENDING ACENC'Y I hereby alftrri that there is a construction lending agency for the performance of the work for which this pemrt is issued(Sects Y197, (civil C tkk) Lender's Name Lender' Address NT<!1C�rlu r\�: ■"r�r iri`r�r a• n�T6`TZ)TTT1\/rT r`CATf/`• rviai