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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby aff irrn that 1 am licensed under the provisions of Chapter 9(commencing with Section WWI of Division 3 of the Business and Proi'essions Code, and my license is in full force and effect. License N Cxp.:Date Date Contractor OWNER-BUILDER DECLARATION 1 hereby affirm(hat f am exempt from the Contractors License Law for the following reason(Sec.703 L.S.Business and I'rsfessions Code; Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance.also requires die 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)of Division 3 of the Business and Professions Code)or that he is exempt hcrefrom and the basis for the allegcJ 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)): O 1,as owiter of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sok (Sec.7044,Businc s and Professions Code:The Contractor's License Law docs trot apply to an owner of prope%ty who builds or improves ihcn wt.and who 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 improvement is sold within one year of compmuon.the owner-builder will have the burden of proving that he did pot build or improve for the purpose of sale.) 111.as owner of the property,am exclusively contracting with licensed cottuverors to construct the project(Sec 7044,Business and Profession Code:The Contractor's License Law does not apply to an o%mcc of property who builds or improves thereon,and who contracts ror such projcets with a conlradnr(s) licensed pursuant ea the Contractor's License Law.) ❑I am exempt under Sec. ,fl&P.C.for this reason Dale Owner WORKERS'C�IMPENSATION DECLARATION I hereby affirm that I have a ecctificatc of consent to self-insure,or a certificate of'Workers'Compensation Insurance,ora certified copy thereof(Sec.3800. Lab.C)_ L-xp.Date Company 17 Certified copy is hcrehy furnished ❑Certified copy is Filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE ff7tis scclion need not be completed,if the permit is for one hundred dollars($100)or less) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become suhjccl(o the Workers'Compensation taws of California. _ Date Applicant 'T NOTICE TO APPLICANT:If,after making ihi9 Certificate of Exemption,you should become subject to the Workers'Compensation provisions of llre Labor Cock.you must forthwith comply with such provisions or this perm v shalt be deemed revoked. - r CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction]ending agency for the performance of Lhe work for which this permit is issued(Sec 3097,Civ.Q. Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑1 hereby certify that no excavation Gve(5)or more feet in depth into which a person is required to descend,will be make in connection with work authorized by the permit,and That no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be mare than thirty-six(36)feet high. (Chap.3.2.Grp 2,Art 2.Sec 34),Title 8,C.A.C.). 0 As owner-builder,L will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as neral above,unless such person has a permit to do such work from the division. ❑Division of Industrial Permit No. 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 ordinances and state laws 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. Datc, Applicant i L