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SUB ADDRESS:_____ PERMIT
<br /> LICENSED CONTRACTORS DECLARATION
<br /> ! hereby affurn that I am licensed under the provisions of Chapter 9(conununcing with Section 7000) of Division 3 of the Elusiness and
<br /> Professions Code aril my license is in full force and effect.
<br /> License N _ _ Expiration Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from [tie Contractor's License Law for the following reason (Section 7031.5, Business and Professions
<br /> Code: Any city or county which roquires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance,
<br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's
<br /> License Law (Chapter 9 (cornrnencing with Section 7000) of Division a of the Itusiness and Prolessions Code) or that he Is exempt
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars ($500)):
<br /> ❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the stnrcture is not
<br /> intended or offered for sale (Section 7044, Business and Professions Gode: The contractor's license Law does not apply to an
<br /> owner of property who builds or improves thereon, and who does such work hirnself or through his own employees, provided that
<br /> such Improvements are not intended or offered for sale. If, however, the building or impiovomrml is sold within one year of
<br /> completion, the uwner-builder will have the bwden of proving That he did not build or improve fur the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br /> Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractors) licensed pursuant to the Contractor's License Law.)
<br /> ❑ 1 am exempt under Section , B&FIC for this reason _
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure ora ce1tifir3to of Workers' Compensation Insurance, or a certified copy
<br /> thereof (Section 3800, labor Code).
<br /> Expiration Date Company_-__ . --
<br /> ❑Certified copy is hereby furnished
<br /> ❑ Certified copy is filed with the f_nvironmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not Leo cornploled if the permit is for one hundrod dollars- ,100 or less
<br /> I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to
<br /> become subject to the Workers' Compensation Laws of California.
<br /> Date:_ - -- ,-_-.- Applicant__
<br /> NOTICE TO APPLICANT: If, after making this Coitificale of Exemption, you :.hould become subject to the Workers' Compensation
<br /> provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deerned revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097,
<br /> Civil Code).
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby certify that no excavation live (5) or more toot in depth into which a person is required to descend, will be made In
<br /> connection with work authorized by the permit, and that no building stnrclure, scaffolding, Ialsework, or demolition or dismantling
<br /> thereof, will be more than 11mly-six (36) feel high. (Chapter 3.2, Group 2, Article 2, Section 341, title 8, California Administrative
<br /> CcdC).
<br /> ❑ AS o„nor-L:uilder I will not omnloy anvonn t0 d(1 Wnrk !I?irb arnriL{ roq--;iro % i nrrrtit froin the Division o! !ndL:Cf,70! .C-al.^,1y, ".3'--d
<br /> above, unless such person has a permit to do such work from the division.
<br /> ❑ Division of Industrial Safety Permit M _
<br /> 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
<br /> ordinances and state laws relating to well construction and or sewago system construction, and hereby authorize representatives of this
<br /> county to enter upon the abovo-montioned proporty for inspection purposes.
<br /> Date - - - ---- -------- - .. --- Applicant --- -- - -- - -
<br /> END 43.02.007 LICENSED CONir1AGIOHS DECLAHATION
<br /> 6-2609
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