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r l JOB ADDRESS:_-- PERMIT#: I LICENSED CONTRACTORS DECLARATION 1 hereby affirm chat I am licensed under the provisions of Chapter?(commencing with Section 7000)of Division 3 of the Business and Pro(ess'sons Code, j `f + and my license is in full force and effect. License fr_ __ F.xp.:Da1e__„ Date_— Contractor_.-- OW NER•BUILDER DECLARATION I hereby affirm that f aur exempt tion the Contractor's License Law for the following reason(Sec.7/13 5.5.Business and Prrfessions Cade; Any city or county which requires a permit to construct,alter,i mprove.demolish,or repair any stcuctum,prior to its issuance,Ulan requires the applicant for such permit ro File a signed statement that he;s licensed pursuant ro the provisions of the Cnmractor's License Law(Chapter 7(commencing with Section 7000)of J Division 3 of the Business and Professions Code)o,that he is exempt herefrom and the basis for the alleged exemption. Any violation Df Section 7031.5 by 1 any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5001): 111.as owner of the Qtapcay,or my employees With wages as their sole compensation,will do the work,and the srrucmre isnot intended or offered for sale (See.7044,Business and Professions Code:The Conuractor's License Law sloes not apply to an owner of propcuy who builds or improves thereon,and who I does such work hirnself or through his own employees,provided that such improvements are not intended or offered for sale. If,however,the building or li 1 an ruvemert is sold within one year of complain._rhe owner-builder wilt have rhe harden of proving that he did not build of improve for the purposc of j sale.) I ❑1.as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:'Ihe Contractors License Law does not apply to an owner of property who builds or improves thereon.and who contracts for such projects with a comractor(s) licensed purvuant to the Cunwackor's Licenk.Law.) 111 am exempt under Sen. ,B @ P.C.for this reason i Date Owner WORKERS'COMPENSATION DECLARATION A i1 hereby affirm that 1 have a certificate of consent to self-insure,or a ceRiricate of Workers'Compensation Insurance,or a cerfificd copy thereof(Sec.38(10, iLah.Q. i Exp.Date_ — __Company_: O Certified copy is hereby furnished I Cl Certified copy is tiled with the County Building Inspection Division CERTIFICATE OF FUMPIION FROM WORKERS'COMPENSATION INSURANCE ' (This section need not be completed,if the permit is for one hundred dollars(5100)or less) I certify that In the performance of the work for which this permit is issued.1 shall not emptey any person in any manner so as to hec0nne subject tat he II Workers'Compensation Laws of California. 1 Date Applicant_ — NOTICY TO APPLICANT:Ir,after making chis Certificate of Exemption,you shnuld becorrc subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply with such provisions or this permit shall he deemed revolted. CONSTRUCTION LENDING AGENCY i I hereby affirm that there is a cunsuuction funding agency for the performarice of the work for which this permit is issued(Sec.3097.Civ.C). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CF,RTIFICATION: I R 1 hereby ecnily that no excavation five(5)or more feet to depth into which a person is required to descend.will be make in connection with work , nuc hurized by the permit,anJ chat no building structure,scaffolding,falsewark,ur demolition or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2.Grp 2.Art 2,Sec 34 L-ritk B,C.A.C.). ❑As owner-builder.I will nor employ anyone to do work which would recluire a permit from the Division of Industrial Safety,as noted shove,unless such Person has a permit to do such work from the division } ' ❑Division of Industrial Permit No. I ceclify that I nave read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relariog to well Canstrtictior,and nr sewage system construction,and hereby authorize repmsentativcs of this city to enter upon the above-mentioned property for inspccrion purposes. i. ,1 Doc Applicant --