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V JOB ADDRESS PEWIIT LICENSED CONTRACTORS DECLARATION JI 1 hereby affirm that I em licensed under the provisions of Chapter 9(commencing with Sector.7000)of Division 3 of the Business end Proressioru Code and my license is in full force and effect License 1116 Z 1 Expiration Date 0-7131124n Data ( CoMraeew — Qp J T 6,— OWNER-BUILDER DECLARATIONrJ I hereby affirm that I am exempt from the Contractor.License Law for the following reason(Section 7031 5,Business and Professions Code. Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure, I also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the mor o ds us of the suan _ cs, j License Law(Chapter 9(Commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt ?a:�and Me basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit suppects the applicant Penalty of not more than five hundred dollars I$Soo))- ❑1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not 1 intended or offered for sale(Section 7044.Business and Professions Code:The contractors License Law doss not appy to an owner of property who builds Of Improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale If,however,the building or improvement u soldwithin one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale) ❑I,as owner of the property.am axcJuswdy contracting with licensed contractors to construct the protect(Section 7014,Business aro Professions Code(BBPC). The Contractor's License Law does not apply to an owner of property who builds or Improves hereon, and who constructs for such projects with E COntfactor(.)licensed pursuant to the Contractions License Law) ❑I am exempt under Section B6PC for this reason — Dao: Owner WORKERS'COMPENSATION DECLARATION I ri affirm that I have a Certificate Of consent to self-insure or a Certificate of WoMOW Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company____ ❑Certified copy is hereby furnished ❑Certified copy is filed with the Enwronmental Heald,Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This$MOD nfteed not be.1=21ified if the permit is fa one hundred dollen S 1 DD a less I certify that In the performance of the work for which this Permit Is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Data: Applicant _ NOTICE TO APPLICANT R.after making this Certificate of Exemption,you should become subject to the workers'Compensation Provisions of the Labor Code.you must forthwith comply with such provisions or this permit shall be deemetl revoked CONSTRUCTION LENDING AGENCY I Hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued(Section 3097, Civil Code) Lender's Name Lender's 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 descendwill be made in Connection with work authorized by the Parini and that no budding structure,scaffolding,falsewoik,a demolition or dismantling thereof,will be more than thirty-six(36)feet high (Chapter 3.2.Group 2.Article 2,Section 341 Title B,California Administrative Code) 0 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 person has a Permit to do such work from the division E3 Division of Industrial Safely Permit a I Certify,that I have read this application and atateahi t to above information is corect. I agree to comply with all Cay and county ordinances and state laws relating to wed i OMMJetfon and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes Date _ -- ---- Applicant E11D IYpl4x17 6-269. --17-C. ICENSED CONTR4C TOR9 DECURATgN