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JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS 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. t '
<br /> License# Expiration Date ,t -
<br /> Date Contractor
<br /> _ OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I 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 requires 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 the basis 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 /> ❑ I,-as-owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.),
<br /> ❑ I,tas 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 hereon,-
<br /> and
<br /> ereonand who constructs for such projects with a eontractor(s)licensed pursuant to the Contractor's License Law,)
<br /> ❑I am exempt under Section _, B&PC for this reason
<br /> r
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent 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 /> It 'l
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the perinit is for one hundred dollars($100)or less)
<br /> I certify that in the performance of the work for which this permit is issued,I sball not_employ any person in any manner so as to
<br /> become subject to the Workers'Compensation Laws of California. .
<br /> Date: Applicant +
<br /> i
<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 /> t , CONSTRUCTION LENDING AGENCY,, .
<br /> I hereby affirm that there is a construction lending agency for the.perforrnance of the work for which this permit is issued(Section
<br /> i
<br /> 3097,Civil Code). � , - , - - - - - , - - -
<br /> 1. 4_.' l
<br /> Lender's Name
<br /> Lender'Address l
<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 irrequired 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 /> --Cade).- •- -^- - - — - _ .._ ._- _ _. ;`- - -- --
<br /> ❑As owner-builder; I will not employ anyone todo-worak Which would-require perrmf from thie Dives on`o\dustrial Safety,as
<br /> noted above,unless such person has a permit to do such'46C46in'the division
<br /> ❑Division of Industrial Safety Permit#
<br /> I certify that I have read this application and state that the above informations orrect. I agree to comply with all,city and county
<br /> ordinances and state laws relating to well construction and"or sewage system construction an`&hereby'autliorize. epresentatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant \
<br /> EH'
<br /> 43-02-007 ,+ ' � C±�1:tt 1 '1 12/23)2003
<br /> Water Well Permit Contractor Declaraction 4-02
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