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f JOB ADDRESS: PERMIT Z, LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 70001 of Di sion 3 of the Business and Prde",drs Code and my license is in full force and effect License t Ci5y Zlo� _ Expiration Data 07 111, 3 Debts_ Co - t`K ,) ilr _ OWNER-BUILDER DECLARATION ( �O Contractor's License Law for the following reason(Section 7031 S.Business and Professions I hereby alfam that I am exempt from th0 Code Any coy of county which requires a permit to ConsWct WEST,improve,demolish.or repair any structure.prior to m issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the Provisions d the Contractor's License Law(Chapter 9(commencing with Section 7000)d Division 3 of the Business and herefrom and tto Code)or that he o exempt una bows for the alleged exemption Any Milstein of Secbm 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty Of not more than five hundred dollars($500)) ❑I,as owner at the property,or my employees with wages as their sole compensation w;li do the work,and the structure is not Intended or offered for sale(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 awn employees,provided that I such improvements are not intended or offered for sale If, however,the building of Improvement is add within one year of icompletion,the owner-bwlder wit 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 project(Section 704.Business and Professions Code(BBPC). The Contractor's License Law does not apply to an owner of property who builds or improves hereon and who conseudts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law) ❑1 am exempt under Section_ Ba PC for this reason Data:_ _---_ - WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to salf-insure or a certificate of WorkersCompensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company_______ ❑Cendied co py is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (Shin section need not be 92Mpleted If the Permit is for one hundred do8ars 1§100 I certify that in the Performance of the work for which this permit isissued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Dna: Applicant NOTICE TO APPLICANT.ff,after making this Certificate of Exemption,you should became subject to the 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 there is a construction lending agency for the performance d are work for which this permit is Issued(Section 3097. Cml Code) Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑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 permL and that no building structure,scaffolding falsework.or demolition or dismantling thereof.will be more than thirty-six(36)feet high.(Chapter 3.2.Group 2.Article 2,Section 341.Title 0,California Administrative Code) O 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 ❑Division of industrial Safety Permit a I Penny that I have read this application and state 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 EMD�3-bt-007 e26-C9 LICENSED CONTRACTORS DECORATION 1G }