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<br /> JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
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<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,
<br /> and my license is in full force and effect. 11
<br /> License>< Exp.:Dwc
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exerapt from the Contractor's License Law for the fallowing reason(Sec.7031.5,Business and Professions Code; Any city ar
<br /> county which requires a permit to construct,alter,improve.demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
<br /> to file a sighed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption, .y
<br /> g prion, Any violation of Section 7031.5 by
<br /> any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($50u)):
<br /> ❑Las owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered forsak
<br /> (Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who
<br /> does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,however,the building or
<br /> improvement is sold 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
<br /> sale.)
<br /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:The
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<br /> Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)
<br /> licensed pursuant to the Contractor's License Law.) +
<br /> ❑1 am exempt under Sec. ,B&P.C.for this reason
<br /> Dale Owner
<br /> WORKERS'COMPENSATION DECLARATION
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<br /> I hereby affirm that 1 have a certificate of consent to self-insure,or a certificate of Norkcrs'Compensation insurance,or a certified copy thereof(Sec,3800,
<br /> Lab.Q. I
<br /> Exp.Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the County Building Inspection Divisioh
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<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
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<br /> (Chis section need not be completed,if the permit is for one hundred dollars($100)or less) k
<br /> I certify that in the performance of the work for which this permit is issued,I shall not emplov any person in any manner so as to become subject to he
<br /> Workers'Compensation Laws of California. )
<br /> Data Applicant IL—
<br /> NOTICE
<br /> ,_NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subtest to the Workers'Compensation provisions of the
<br /> Labor Code,you must forthwith comply with such provisions or this permit shall be dee}md rexoked. '
<br /> CONSTRUCTION LENDING AGENCY
<br /> 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ,C). 'lk
<br /> Lender's Name _ t
<br /> Lender's Address f
<br /> DIVISION OF INDUSTRIAL SAKTY PERMIT CERTIFICATION: }
<br /> ❑1 hereby certify that no excavation five(5)or more feet in depth into which a'person is required to descend,will be make in connection with work
<br /> authorized by the permit,ani that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet )
<br /> high. (Chap.3.2,Grp 2,Art 2,Sec 341,Title 8,C.A,C.).
<br /> ❑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
<br /> person has a permit to do such work from the division.
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<br /> ❑Division of Industrial Perndt No.
<br /> 1 certify that I have read this application and state that the above information is correct. I agree to:comply with all city and county ordinamrs and state laws
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this city to enter upon the above.mentioned property
<br /> for inspection purposes.
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<br /> Dale_ Applicant
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