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JCIB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Pmfessions Cock, and my license is in full force and effect. License# Exp.:Date nate Concraetor OWNER-BUILDER DECLARATION 1 hereby affirm that l am exempt from the Contractor's License Law for the following reason(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure.prior to its issuance,also requires the applicant for sttch permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(corranencing with Section 7000)of Division.1 of the Business and Prcfessions Code)or that he is exempt herefrom and the basis for the alleged exempdc.n. Any violation of Section 7031.5 by any applicant for a permit subjects dic applicant io a civil penalty of not more than five hundred dollars ($500)): ❑1,as 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 for sale (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 I does such work himself or through his own employees.provided that such improvements ate not intended or offered for sale. If,however,the building or 1 improvement is sold within one year of completion,the owner-builder will have the burden of proving that,'-&did not build or improve for the purpose of sale.) ❑I,as owner of the property,am exclusively con;racring with licensed contractors to construct the project(Set.7044,Business and Profession Code_The 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) licensed pursuant to tlw Contractor's License Law.) ❑I am exempt under Sec. B&P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800, Lah.C). Exp-Date Company _ ❑Certified copy is hereby furnished y ❑Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMP71ON FROM WORKERS'COMPENSATION INSURANCE CThis section need not be completed,if the permit is for one ht:ndred dollars(SIO(J)or lens) 1 certify that in the performance of the work for which this p!-rrnit is issued,1 shall not employ any person in any manner so as to become subject tot he I Workers'Compensation Laws of California. Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subjkv to the Workers'Compensation provisions of the 4 Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perforrnance of the work for which this permit is issued(Sec.3097,Civ,Q. Lender's Name Lender's Address ! DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION-. ❑I hereby certify shat no excavation five(5)or more feet in depth into which a person is required to descend,will he mak:.in connection with work i authonzed by the permit,apd that no building structure.scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Grp 2,An 2,Sec 341,Title 8,C.A.C.)- 4 ❑As owner-builder,I will nor employ anyone to do work which would require a permit from the Division of Industrial Safety,se rioted above,unless such person has a permit t-o do such work from the division. ❑Diviyion of lnr:ustriai Permit No. I certify thin I have read this application and state that the above information is correct. I agree to comply withvll city and county ordinances and state laws t1 relating to well construction and or sewage symem construction,n,and hereby authorize reprewritatives of this city to enter upon the above-mentioned property for ins ct;on u ' Pc P u3xrscs. f Date Applicant 5 L