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<br /> JOI3 ADDRESS: PERMIT k: _
<br /> LICENSED CONTRACTORS DECLARATION
<br /> ! I hereby at:ins+that I am fieensed uadcr the provisions of Chaptcr 9(comrcen,ins with Sce inn 7(NNI)of Division 3 of the B—ine"and Pn;fcsvmns Code. I
<br /> and Iny lir,nsc Is in full force and cflcc(
<br /> Dalc_ Cunuactur_ __
<br /> OWNER-BUILDER DECLARATION
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<br /> 1 hereby affirm that I am exempt from the Contractor's License law fcr Ute fullowing reason(Sec.703 t.5,Buvoess and Profcssions Code; Any city or
<br /> county whicr.requires a permit h construct,alter,improve,demolish,or icpau any suuctute,prior to its issuance,alsu rafuires the applicant for sues permit
<br /> to file a signed statement that he IS ficcnsW pursuant to the provisions o!the Conmetor'y Liaise Law(Chapter 9(commencing with Section 7((X1)of
<br /> Division 3 of the Bust ncss and Prol—cos Code)or that he is exempt hese;rom and the basis for the at lcgcd excmplioa. Any viol tion of Sallow 703 t.5 by
<br /> oay applicant fur a permit subjects the apph can;to a civil penalty of not more Ilian five hundred dollars ($500))
<br /> 0 1,as owner of the propcny.or my employers with wages as their su:c i-urnpcusatioa,wJl do the work,and Ilio structure Is not intended or offered for sale
<br /> (Sec.7044,Business and Professions Code The Cnntractor's Licetrac I--docs not apply to an owner of property who builds or improves thereon,and wlso �
<br /> does such work himself or through his own employees,provided that such improvements are not mended or offered for sale. If,h0WCVU.the bolding or
<br /> improvement is sold within one year of completion,the owner-builder sal:h.1i e the burden of-proving that lie did not build or improve for the pt rpra.:of
<br /> sale.)
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<br /> 0[.as owner of the property,am exclusively contrsting with licensed contractors to construct the project(Sec.7044,Business and Profession Cmle:The
<br /> Contraemr's License Law don not apply to an uwner of property who'owIds or Improves thereon,and who contracts for such projects with a contract,it($)
<br /> licensed pursuant to the Contractors Licensc Law.)
<br /> 0 1 am cxertipl under Scc. ,B k P.C.for 11-,,nn
<br /> Dale Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> hereby affirm that 1 have a certificate of cunsent to self-insure,or a cesarcae of Workers'Compensation lnsuranee,or a certified copy thereof(Sea 3800.
<br /> Lab.C).
<br /> Lxp,Date Company
<br /> 0 Certified copy is hereby furnished
<br /> O Certified copy is filed with dw County Building Inspecuon Divisicn
<br /> CERTIFICATE.OF EXEMPTION FROM WORKER3'COMPENSATION INSURANCE
<br /> ;Thus section need not be completed,if(Se permit is[or one hcndred dollars(S 100)or less)
<br /> I certify that in the performance of the work for which this frrmt is issued,1%lull not employ any person in any manner so as to become subloci In the
<br /> Workers'Compensation Laws of Ca)iforr.ia.
<br /> Date Applicant _-- -
<br /> NO'I ICE TO APPLICANT:If.afier nuking this Ccrlificate of Lxempiion,you should become subject to the Workcrs'Cumpeivalion pr--eros of the
<br /> 1 shnr Code,you must forthwith comply with such provisions or this permH %lull be dcemsed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm Out there Is a consuucrnn banding agency for the Performance of the work for which this permit is issued(Sec.3097,C)v.Q.
<br /> Lender's
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> C3 I Hereby ccrufy that nu excavation five(5)or n;ore feet in depth into whic a person is required to descend,will be nuke in connection with work
<br /> authorized by the permit.ani that no building structure,scaffolding,falscwark,or demolition or dismantling thereof,will he inure thin Thirty-six(36)feet
<br /> high. (Chap.3.2,G p 2,An 2.Sec 341,Tide 8,C.A.C.).
<br /> O As owner-builder,I-will not employ anyone w do work which would rcgairc a permit from the Division of Industrial Safety,as noted above,urllcm such
<br /> person has a pernut tc do such work from the division.
<br /> 0 Dlviston of Inda owl Permit No.
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<br /> 1 certdy tha(1 Iia%'e road tl11x application and Sla(C that IIIC above L'If0l nia(luri❑correct. I agree IU comply with all city and county ordinances and state laws
<br /> relating to wc11 construction and or sewage system construction,and hereby androrize representatives of this county to enter upun the above-mel,honed
<br /> property fcr Inspection purposes.
<br /> Date_ Applicant
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