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JOB ADDRESS: PERMIT!i':
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License#_ Expiration Date
<br /> Dale Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that i am exempt from the Contractor's License Law for the following reason (Section 7031,5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to
<br /> its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any.-pplicant for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)): 1
<br /> ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> intended or offered for sale (Section 7044, Business and Professions Code: The contractor', License Law does not apply to an
<br /> owner of property who builds or iinprovcs thereon, and who does such work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br /> and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑ I am exempt under Section MPC for this reason
<br /> Date: Owner
<br /> WORKERS'CONZIPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3800, Labor Code).
<br /> Expiration Date Company _
<br /> ❑Certified copy is hereby furnished —
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION:F ROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100)or les
<br /> 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
<br /> become subject to the Workers' Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, after rivking this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed 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
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender' Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 13 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
<br /> connection with work authorized by the permit, and that no building structure, scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341,Title 8,California Administrative
<br /> Code).
<br /> ❑ As owrier-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ,❑ Division of Industrial Safety Permit ti
<br /> I certif, 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 sewage system construction, and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 LICENSED CONTRAC TORS DECLARATION
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