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soil West Mussdale,I alhrop,CA 95330
<br /> JOB ADDRESS:_- PFAYR C:
<br /> UCENSED CONTRACTORS DECLARATION
<br /> I ifereby aMi m RLet I an fK;wusud under the prursion:;of Ctioptur 9 wrh Seelr•_:n 7(0(1)of Division 3 of the-Business and
<br /> Profesaons Code aro my Imrtso Its In fu1 force:sd trffw;.
<br /> Ucenso 8 710079 Expiration Date 713015
<br /> Date 4�'� .-- Contractor i 1
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby afram that I am exempt trop the Cortr.clOr's L.rconu Law rx Rue foM1cnvvv_r mason(Section 70315,Iltasirx:ss and Profuss.or'
<br /> Corr Any City or county which reCu►es a permit to construct otter,tmprwe,dernci sh,or repar any structure,prior to Its Issuance.
<br /> a(So requires the app(4-vd for such ponnC to Ne a signed statement that he is icerno d pursuant to iho pmvmions of Cin Contractoen
<br /> License Lew(Chapter 9(comrmoncrg v,10-Soann 70oo)of Division 3 0`.tho Gusinors and Professions Codes)or tMt he is exempt
<br /> I&-m turn and the boam for the alleged exemption Any violation of Section 7031.5 by arty applicant for a permit subjects Re applicant
<br /> I to a chit penailY of not more than fir hxrndred do Yuri($500))
<br /> O I,as owner o1 the proporty,or my empkhyens with wages as their sole compensation,will do the wxk,and the sauct:re Is not
<br /> intended or offered for save(So:ion 7044,Husrrx;ss and Professions Cada' The comtraGors Licuneo Law does not apply to an
<br /> owner of propmty who builds or knprcr ms thereon,and who does such work hmhseLf or through his own PfnhpbyPes,provided that
<br /> svrch Improvuments are not in onded or olored for sr.ie If however, t W bct.dalq or impranrmonx is snid wth n cne yea., of
<br /> completion,the owner-bi hider will have the burd.xr of pri-Anq that he.dM not bu Id or rmprovo for"purpo:+r of sok j
<br /> OF,,as owner of the property.am exclusively carrtraCfng w:h I.censed contra tors to construct the protect(Section 70",Business and
<br /> Pry csaorts Code(B&PC)'. The Camra-,,or'sLicenseLe Law floes not apply to an o«nar of property Who but Or improves hereon,
<br /> nnei who constricts for such pro)P,a WTI a xntmc tur(s)Licensed pursuant to the CorAselors License Low)
<br /> 13 1 am exempt under Section BSPC dor this reason - --
<br /> Date: Owner_ - - — - - - -
<br /> WORKERS COMPENSATION DECLARATION
<br /> I hereby afintn lfut I have a eertfic;Ae of consent to sehf4risure or a cortifirate of WOfk@W CampensiMOrl hawl'SnCA,ora
<br /> ceftifired copy thereof(Setbon 3800,Labor Code).
<br /> Expiration Date. (� ) c , Company t
<br /> D Cvrtihod copy is hereby furnishxxf
<br /> O Ceftified copy is fded with the Errrironrnental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> TThiis secton recd riot tx�cnmPleted if t1e-Purr it is for ong htnK red ddlars($1tX)�or 11
<br /> I certify L'>at in tux:performance of the work for which this p.xrnit is issued.I shat not emptoy any person in any nlinfl6r so
<br /> as to bocomo subject to the Wencers'Compuerlsation Laws of California
<br /> Date: Applicaint —-- --- __.
<br /> NOTICE TO APPLICANT:M,ate,makrrxJ this C MAlcate of EAempron,you should become subject b Cie WID&ATW Compensation
<br /> provisions of the Labor Code.you must forthwith comply wUl such prc'.'sm,;or this permit shah be deemed revoked
<br /> CONSTRUCTION LENDING AGENCY
<br /> I Hereby affirm that there is.)constnuctfon lendtap agxlCy hof the performance of t)1e woo'cr v hich this permit is issued
<br /> ($idiom 309? �r.'il Code}
<br /> Lenders Name --
<br /> Lander Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> 0 1 hereby certfy that no oxcavatdon five (5) of nam feet in depth Imo which a person is(e,u,red Ir)descend. wh11 be made in
<br /> Connection with work authhonz-od by tho permit and that ne budd,rg structure,scaffolding.fai•,ework,Or derrickon or drsmantlirxJ
<br /> thereof. ,itl be,meso th ri n thirty-six(36)toot high (Cl:aptor 12.(1nxtp 2.Article 2.Secbcn 341,Title 8,California Adtnnrsti'an%V
<br /> Code).
<br /> Q As o.vnerbunldmr.I wil not nmpoy anyone to do work wh+cn would require it thur bt vtxr;R+u G�vis.cn u!hxluseLhl S.Aoy.os noted
<br /> subrrvo,urJe%3 such pernon has a pormt to do serh vmrk from the dvslon
<br /> ❑Dirvisw, of indusRdal Sudety Ponrei 0 _-_ — --
<br /> bort afd 5011 Cue the ntxrre infonrot,on:L eccruet. 1 agree to comply with aq city and eourttY
<br /> I u�rUty L'a:I have read Rus appsrt tadl tree
<br /> ordnarcm and state Isms ndawv to well coreluctlon and Of Sewage system mrstM3ion.and hereby atNho=represt nof this
<br /> county to enter upon Cha ar ovminerruoned IxrKx-rty for rnsper:tlon purpox,
<br /> Dote _ ____ _ Applicant
<br /> L,cuut.o can rnwcrwc uccax�non
<br /> FNn 4347
<br /> IOJ97
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