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JOB ADDRESS: PERMIT Ill -- LICENSED CONTRACTORS DECLARATION fi I hereoy affirm that 1 em licensed under the provisions d Chapter 9(commencing wrtn Section 7000)of Dir,sion 3 d the Business and PrdessiOrs Code and my license Is in lull force and sheet License It y54 Z( -1 Expiration Date 07 3 in � __` Contractor �Deft '24>-Z,X ZJ I _ / ONMER-BUILDER DECLARATION �`O jl hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031 5,Business sr.d Professions Code. Any city or county whim roqulma a permit 10 construct.alter,impmve,demolish.or repair any structure,Prior to its issuance, also mqukea the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions d the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 Of the Business and Profeuions Code)or that he:s exempt herefrom and the basis for the alleged exemption Any violation d Section 7037.5 by any applicant for a permit subl"- the applicant to a Civil penalty of not more than five hundred dollars($500)) 13 1,as owner of the property,or my employees with wages as their sole compensation w,ii do the wwkand rhe s d trvct im rs not intended or offered for Sale(Section 7044,Business and Professions Code'The contractors License Law does ria apply for an owner property builds or Improves thereon,and who does such work himselfor through his own employees,provided mat such improvements are not intended or offered for sale If, however,the buiding or improvement is sold within one year d 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 exclusively contracting with licensed Contractors to construct the protect ISrsUCon 7041,Business and i Professions Code(BSPC). The Contractors License Law does not apply to an owner of property who builds or Improves hereon. and who constructs for such projects with a contrechn(s)licensed pursuant l0 the Contractors License Law.) 0 1 am exempt under Section_ Ba PC for this reason Data:_ - Owner WORKERS'COMPENSATION DECLARATION I hereby aft,that 1 have a certificate of consent to self-insure or a certificate of Workers Compensation Insurance,or a candied copy fl! thereof(Section 3800,labor Code) Expiration Date____ __ Company__ — ❑Certified copy is hereby fumished C3 Certified copy is tied with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE LTrvs section need not be v If ed If ted Darton s t hundred doge s C 51001 or I certAy Mal m the perforrnance d the work for which this permit Is issued.I shall not employ any person.In any manner so as to I become sut>)ect 0 the Workers'Compensation Laws of Caliromie. Date Applicant NOTICE TO APPLICANT:N.alter making this Certificate of Exemption,you should become subpct to the WorkersCompensation provisions of the Labor Code,YOU mull forthwith comply with such provisions or this permit shall Oe deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that Mere is a ConsWetion 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 O 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 that no budding structur,.scaffolding,fabework.or demolition or omman" thereof will be mora than thirty-six(38)feet nigh (Chapter 3 2.Group 2 Article 2.Section 341 Title 8,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 perut to do such worts from the division O Division of Industrial Safety Permit a 1 certify Mat 1 have read this applicatpn and stale that the above information is Correct I 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 Data ---- _ Applicant END 4J-0Q.op7 1L26-C9 LICENSED CONTRACTORS DECUBATION It:el 11 i