SR0080841 SSCRPT - Laserfiche WebLink

Home Browse Search

JoaADOREss:31 ,CC> ko.4T) 7P-QC-Y— PEFMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am ficensed 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 License# Expiration Date Data Contractor + OWNER43UILDM DECLARATION II I hereby affirm that I am exempt from the Contracxofs License Law for the fo0owing reason(Section 7031.5,Business and Professions [ Code: Any city or county which requires a permit to construct,atter,improve,demoksh,or repair any structure,prior to its issuance, also requires the applicant for such permit to%a signed statement that he is fieernsed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing wfth Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7D31.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)): ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the strt>cfure is not intended or offered for sate(Section 7044,Business and Professions Code:The contractors 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-0uitder wllf have the burden of proving that he did not build or improve for the purpose of sale.) ❑1,as owner offt property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and - Professions Code(B&PC): The Contracdnrs License Law does not apply to an owner of property who builds or Improves hereon, and who catsbucts for such pmiKts with a contractors)licensed Wrsranl to the ConttraCtors license law.) ❑1 am exempt under Section B&PC for this reason _ ! Date: Owner: WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a Certificate of consent to self4rlsure or a certificate of Vvbrkets'Corripensatlon Insurance,or a certified copy thereof(Section 3800,Labor Code). ,� �y Expiration Date 3 ' ' 240 Carrlparrlr, rV lVt�✓dQ� l��il, 1l1C_ LO�l1' ACertified 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 eomDleted If ft-Peri[is for one hundred dollars($700)or less) I certify that in the performance of the work for vd*c:h this permit Is issued,i shag not employ any person In any manner so as to become subject to the Workers'Compensation Lows of CaRfomia. Data: Applicant NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must fortfrwMh comply with such provisions or this pemdf shall be deemed revoked. CONSTRUCTION LENDING AGENCY I I hereby affirm that there is a owtstruction lending agency for the performance of the work for which this permit is issued (Section 3097,CM Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 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 than no building structure,scaffolding,falsework.or demolftion or dismantling thereof,Will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,TMe 8,Catifomia Administrative Code). ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such parson has a permit to do such work from the division. ❑Division of Industrial Safety Permit a _ I certify that I have read this application and slate that ttte above information Is correct I agree to comply with aM city and county ordinances and state laws relating to Weil construction and or sewage system consittaction,and hereby authorize representatives of this county to enter upon the above-rrd property for inspection purposes. DateApplicant EH 43-07 ��/ LICENSED CONIAAGI OR DECLARATION W15007 1 ( VVV