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JOB ADDRESS: PERMIT# i LICENSED CONTRACTORS DECLARATION ' I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business 1 and Professions Code and my license is in full force and effect. License# _ _ _ _ Expiration Date Date Contractor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.3, Business and Ptofessions Code: Any city or county which requires s permit to ennstruct,alter,improve,demolish,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 provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the Business and Professions 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($500)): CI L as owner of the property,or my employeeswith wages as their sole compensation,will do the work,and th structure is not intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not ply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, vided that such unprovements are not intended or offered for sale. If,however,the building or improvement.is sold within one of completion, the owner-builder will have the burden of proving that be did not build or'improve for the purpose of sale.) ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project($ n 7044,Business and Professions Code(B&PC): The COnttaft*r's License Law does not apply to an owner of property w � improves hereon f and who constructs for such projects with a coniTactor(s)licensed pursuant to the Contractor's License I avt O I am exempt under Section._, E&PC for this reason Date: Owner 1 s r I WORKERS,COMPENSATION DECLARATION' I I hereby affirm that I have a certificate of consent to self-insure;or a certificate of Workers'Compo on Instaane ,or a certified copy thereof(Section 3800,Labor Code). l Expiration Date Company Q Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEbIPTION FROM WORKERS'COMPE SATION II1 AItANCZ (This section need not be completed if the permit is for one hundred dollar7sh�aLi or less I certify that in the performance of the work for whizh this permit is issuednot nyperson in any manner so as to become subject to the Workers'ComPensanon Laws of CaliforniaDate• Applicant NOTICE TO APPLICAPIT: If, after making this Certificate of En, should become subject to the Workers' Compensation provisions of the Labor Code,you must forthwith comply ilp it shall be deemed 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). Leader's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CER ICATI0Ne� E3 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 permit,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 9,California Administrative Code)_ ❑As owner-builder,I will not employ anyone to do work which would require a permit,from the Division of Indwitrial Safety,as noted above,unless such person has a permit to do such work fromthe division. ❑Division of Industriai Safety Permit#`_— -_.,_—` i certify 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 lave=s 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. Date Applicant i EHD 43-024W MASTER Water Nett Permit Contractor Deciaracrian 1i }21S12t562 I