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JOB ADDRESS:_ __ PERMIT#: LICENSED CONTRACTORS DECLARATION i 1 hereby affirm that i atm licensed under the provisions of Chapter 9(commencing with Section 70001)of Division 3 of the Business and Pro:essions Cede, and my license is in full force and effect. License p Exp.:Datc _..._ __— Date ONVNF.R-BCILDER DECLAR-4TION I hereby affirm that I am exempt from the Contractor's License law for the fullowing reason(Sec.7031.5.Business and Professions.Code- Any city or comity which requires a permit to construct,alter,improve,demolish,of repair any,structure,prior to its issuance.also requires the applicant for such perrttit to file a signed statement that he is licensed pursuant to the provisions of the Coottaclor's License Law(Chapter 9(coil) fencing with Section 7000;of Division 3 of the Business and Professions Code)or that he is exempt heret'rom and the basis for the alleged exclnprioa. Any violation of Section'031.5 by any applicant for a perntil subjects the applicant to a civil penally of not more than five hundred dollars ($5(x1)1: ❑I,as owner of the property,or my crop loyces with wagCs as their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044,Business and Professions Cock:The Contractor's License Law docs not apply it)an owner of property who buiids or improves thereon,and who does such work himself or through his own^nrployees,provided that such improvements an not intended or offered for sale. If,however.the building of improvement is told within 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.) ❑1,as owner of the property,am exclusively tontracung with licensed contractors to construct the project(Sc-c.7045,Business and Profession Code:The Contractor's License LAw docs not apple to an ovine-of property who builds or improves thereon, ind who contructs for such projects with a contracio r(s) licensed pursuant to the Contractnr's License law.) 4 ❑I am exempt under Sec._ R h P.C.for this reason Date _ Owner WORKERS'COMPENSATION DECLARATION I hereby affirm That I have a certificate of consent to self-insure,or a cetaificatr-ul Workers'ComltcttsatiotL In5lrra11CC,of it ccrttfted copy►lsefeaf(See.38W, Lab.C). I Exp.Daft_ Company ❑Certified copy is hereby furnished ❑Certified Copy is filed with the County Building[nspecti.m Divisum CERTIFICATE OF EXEMPTION FROM W'OR"AtS'COMPENSATION INSURANCE (This section treed not be completed,if the pernut is for one hundred dollars(S11N))or less/ 1 certify that in the performance of the work for which this fyinut is issued,I shall not employ any person in any manner so as to become subject tot he Workers'Compensation Laws of California. Dale Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become sohjmr to the Workers'Compensation provisions of the I xhor Code,you must forthwith comply with.such provisions or this permit shall be deemed revoked. CONSTRU("fION LENDING A(:F:N" 1 hereby affirm that thein is a construction Ending agency for rhe pe.iformunce of the work for which this Permit is issued(Sou.3097,Civ.C). Lender's Name_ i - Lendcr's Address DIVISION OF INDUSTRIAL SAFETY PERMITCERTIFICATION: ❑1 hecebv certify that no excavation five i51 or more feet in depth into which a person is required to descend,will be make in connection with work authorized bV the permit.anJ that rto building structure,scaffolding,falscwoik.or demolition or ditrnantliog thereof.will be more than thirty-six(;G)feet nigh. (Chap.3.2.Cir,2,A,rt 2,Sec 341,Title 8,C.n.C.). ❑As owner-builder,I sill not employ anyone to do work which would requ:re a pernut from the Divtsion of Industrial Safely,as noted above,unless such person has apermit to do such wort,fnono the division. ❑Division of Industrial Permit No. I certify that I Gave read this applicatun and state that the above infof oration is correct. 1 agree to comply wish all city and county ordinances and state laws relaling to wtR construction and of sewage system construction.and hereby aur .ciii7.representatives of this city to enter upon the ahOVC mentioned Property for inspection purposes. Date_ Applicant L 4 :� ..•