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JLB ADDRESS:
<br /> PERM i1'#:
<br /> LICENSED CONTPUCTORS DECLARATION
<br /> I 1 hcrcby uffirm that i am licensed under the provisions of Chapter 9 Ict)mn,cncing with Section 7(X1))of Division 3 of hhe Rusiness aril Pmiescions Cork;,
<br /> and by license oi in full force acid effect.
<br /> License N Exp.:Dalc
<br /> Dale Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hcrcby affirm Aix I am exempt from the Contractor's License Law for:he following reason(Sec.7031.5,Basn,ess and Professions Code; Any city or
<br /> county which requires a permit w construct,alter,improve,demo)ish,or repair any structure,prior to its Issuance,also mquires the applicant for SU6lxro,it
<br /> to file a signed statement that he i licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(cot vfienctng with Section 7110))of
<br /> Division 3 of the Business and Pmfessions Code)or that he is exempt hcrefrom and the basis for the alleged cxcmptio!r. Any violation of Section 7031.5 by
<br /> any applicant fora pernut subjects the applicant to a civil penally of not more than five hundred dollars ($5001):
<br /> ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intcuded or offered for sale
<br /> (Sec.7044,Business and Professions Cork;The Contractor's License Law docs not apply to an owner of properly who builds or improves thereon,and who
<br /> i does such work himself or through his own employees,provided that such improvements are not intended or offered frn sale. If,however,the building or l
<br /> improvement is sold within one year of completion,the owncr-builder will have clic burden of proving that he did not build or improve for the purpose of t
<br /> sale.) I
<br /> 111.as owner of the property,am exclusively contracting with Iiccnscd contractors to construct the project(Sec.7W4,Business and Profession Cade:The
<br /> Contractor's License Law docs not apply to an ow)icr of property who builds or improves thereon,and who contracts for such projects with a conlractilt(s)
<br /> licenced pursuant 10 the Contractor's License Law,)
<br /> ❑ I ant exempt under Sec. i7&P.C.for this reason
<br /> Date Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> 1 hereby affirm that I have a certificate of consent to self-insure,nr a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3900,
<br /> Lab.C).
<br /> L•xp.Date Company _
<br /> CI Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the County Building Inspection Division
<br /> CERTIFICATE OF EXEMPTiON FROM WORKERS'COMPENSATION INSLIRANCL
<br /> (This section need not be completed,if the permit is for one hundred dollars(S 100)or less)
<br /> I certify,that in the performance of the work for which this prrmt is issued,I shall not employ any person in any manner son as to become suhjeet to the
<br /> Workers'Compensation Laws of California.
<br /> Date Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subjec,to the Workers'Compensation provisions of the
<br /> Labor Code,you must forthwith comply will,such provisions or the permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> i hereby affirm that there is a construction Irnding agency for the performanec of the work for which this permit is issued(Sec.31M)7,Civ.C),
<br /> Lender's Nato:
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAULTY PERMIT CERTIFICA'T'ION:
<br /> I
<br /> ❑1 hereby certify that no exc.vation five(5)or more feet in depth into which a person is required to descend,will be make in connection with work
<br /> authorized by the permit,anti chat no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be store than shiny-six(36)feet
<br /> high. (Chap.3.2,Grp 2,A;t 2,Sec 341.Title 9,C.A C.). i
<br /> ❑As owner-builder.I will not employ anyone:to do work which would requite a permit from clic Division of Industrial Safety,as noicd above,unless suds
<br /> person has a penrut it,do such work from the division.
<br /> ❑Division of Indusirial Permit No.
<br /> I certify that I,:ave read this application and state that the above information is eorree(. I agree to comply witil all city and county ordinances and state laws
<br /> on,and hereby authorize representatives or this county to enter upon the above-mt
<br /> enioned
<br /> relating to writ construction and or sewage system construe,i
<br /> properly for Inspection purposes.
<br /> i
<br /> D.tc_ Applicant _
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