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JOB ADDRESS: PERMIT #: LICENSED CONTRACTORS DECLARATION I hereby affitrn that I urns licensed under the pmvisions of Chapter 9 (commencieg with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect License il Exp..Date Date Cornractor OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (See. 7031.5, Business and PrOfrtsions Code; Any city or county which requires a permit to construct, alter. Improve, demulish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisims of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prefeassons Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500h: 0 I, as owner of the property, or my employees with wages as then sole compensation. will do the work, and the atliCtute is nut totended or offered for sale (Sec. 7044, Business and Professions Code: The COIILFWA01.6 License Law does not apply to an owner of property who Wilds or improves thereon, and who does such work himself or through his own employees, prrAided that such improvements are not intended or offered for sale. If. however, the building or improvement to sold within one year of coats:tenon. the owner-builder will have the burden of proving that he did no( build or improve for the purpose of sale.) 0 1. as owner of the property, am exclusively co/erecting with licensed contractors to construct the project (Soc. 7044. Business and Profession Code: The Contractor's License Law does not apply to an owner of pmperty who builds or improves thereon. and who cons-acts For such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) 0 I arn exempt under Sec. B Et P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell-insure, or a certificate of Workers' Compensation Insurance. or a certified copy thereof (Sec 3800. Lab. C). F.xp Date Company 0 Certified copy is hereby furnished Certified copy is filed with the County Building Inspection Di visioe CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INS IULNCT (This section need not be completed, if the permit is few one hur.dred dollars ($100) or less) I certify that in the performance cif the wock for which this permit is issued. I shall not employ any person in any rummer to, as to become subject tot he Workers' Compensation Laws of California. Date Applicant NCYTICE TO APPLICANT: If, after making this C,mitiente of Exemption. sou should become subject to EIRRICirlatir Componodooprovisiona of she Labor Code, you mui.t fo.Ohwidi comply with such pmvisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm dun there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Ci v. C). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 0 I hereby certify that no exervarion five (5) or more feet in depth into which a person is required to descend, will be make in connection with work sulhonzed by the permit, anti that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will he snore than thidyaix (36) feet high. (Chap. 3.2, Grp 2, its 2, Sec 341, Title C, CA. C.). 0 As owner-builder, I will not employ anyone to do wad( which would require a permit from the Division of Industrial Safety, as noted above, unless such Fenton has a permit to do such work from the divisiere: 0 Division of Industrial Permit No. I cenify that I have read this applieetion mid mate that the above information is correct. I agree to comply with all city and county ordtnanees and state laws naming to well consmiction arid or sewage system construction, and hereby authorize representatives of this city to enter upon the above-mentioned property Dor inspect Mu purposes. Applicant