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1 l !a(,r)i� S '�.lw'wi✓l ffjLJ PERMIT#: Joe ADORESS:_�6�(�/�J • — LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect Expiration Date pL�� ! License# f&E&3 w�/3 Contractor Date OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for fine folkwing reason(Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, ager.Improve,demolish, or repair any structure,prior to its Issuanl also requires the applicant for such permit to file a signed statement Ihaf ne is licensed pursuant f0 the provisions of the Contractor's License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the Busmess and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any volatiorl of Section 7031 5 by any applicant for a permit subjects the applicant to acivil penally of not more than five hundred dollars($500)) ❑ I,as owner of the property, or my employees with wages as their sole compen SatlOn, wltl do the work, and the structure is not intended or offered for safe (Section 7044, Business and Professions Code The contractor's License Law does not apply to an owner of property who builds or improves thereon.and who does such work himself or through his own employees, provided that such Improvements are not intended or offered for sale_ If however. the building or improvement Is sold within one year of completion.the owner-builder will have the burden of proving the;he did riot bu!ld of Improve for the purpose of safe.) ❑I,as owner of the property, am exUusrvely 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 property who builds cf improves hereon, and who constructs(Of such projects with a contractot(s)licensed pursuant to the Contractor's License Law.) ❑1 am exempt under Section _ ._ BBPC lot This reason Date: Owner: WORKERS'COMPENSATION DECLARATION I hereby.afftrm that I have a certificate of consent to sell-insure or a certificale of Workers'Compensation Insurance,or a ` "certified copy thereof(Section-3800:Labor-Code)— —'fTT "" "= – " Expiration Date Company_ _-_ ❑Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be com feted it the germil is for one hundred dollars 100 or l ss I certify that In the performance Of(Ile work for which Ihis permit is issued I shall not employ any person in any manner so as to become Subject t0 the Workers Compensation Laws of California Date: _ Applicant . _ NOTICE TO APPLICANT It, after making this Certificate of Exemption, you should become subject to Ute Workers' Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that Ihere is a construc(ion fending agency for the performance of the work for which this permit is issued (Section-3097.Civil Code) Lender's Name f Lender Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTfFICATION ❑ 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 connection with work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof,wA11 be more than thirty-six (36) feet high. (Chapter 3 2. Group 2.Article 2, Section 341 Title 8. California Administrative Code). ❑As owner-builder.I will not employ anyone 10 do work wh,Ch would require a permit from the Division of Industrial Safety,as noted above,unless such person nas a permit to do such wori,from the division. ❑Dmsion of Industrial Safety Permit a I certify that I have read this application end slate that the above inform8lion IS correct, t agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for Inspection purposes ' Date Applicant LICE NSEO CONTRACTOR DECLARATION