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<br /> } JOB ADDRESS:_— _ PERMIT#.
<br /> `I LICENSED CON'T'RACTORS DECLARATION �
<br /> 1 hereby affirm Char I am licensed under the provisions of Chapter 4 rerumn:ncing with Section 7W))of division 3 of the Husiness and Professions Code,
<br /> and my license is to full force and cffvxt.
<br /> License 8Exp.:datc_-- _--- -- -_—_�_�_—_---_ --
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<br /> Date --Contractor--__---
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<br /> OWNFR-flUI)AWk DECLARATION
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<br /> I hereby rttfsrm That I am exempt front the Contractor'-License Law;r the f:,llowing renNon(Sec.7031.5,Business and Professions Code; Any city or
<br /> county which requires a permit to construct,alter,improve,demolish,or fcp I.r any structure,prior to its issuaece,also requires the applicant for such permit
<br /> to file a sipped statement that he.s licensed pursuant to the pruvtsions rl'tlw C'ontractor's License Law(Chapter 9(commencing with Section 70001 of
<br /> Division 3 of the Business and Prn;essions Cude.l or that he is exempt hcref rem and the basis for the alleged cxempuo,l. Any violation of Section 7031.5 by
<br /> any applicant(or a perinit subjects the applicant to a civil penalty of Pi mere than five hundred dollars (S?f)l)):
<br /> ED 1,as owner of the- property,or my employees with wages as thnr sole ci:nacusatimt.will do the work,and the structure is not intended or offered for sale
<br /> (Six:,7044,BIISMCSS incl Professions Ct1d,.: he Contractor's l scen,;C I.a,v door not apply to an owner of prnpe:ty who builds or improves thereon,and who
<br /> docs such work himself or through his own:mployecs,provided that such rngxuvements are not intended cn offered for sale, If,however,the building or
<br /> improvement is sold wtdnri one year of completion.the owner-builder�kttl'iavc the burden of proving diet he did not build or improve for the pu4)osc of
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<br /> 01,as owner of the property,am exclusively conVacung with licensed conhnctors to construct the project+Sec.7044,Business and Profession Cade'.'me
<br /> Contractor's License law does not apply to an owner of property who builds or improves thereon,oral who coruracts for such pruject-with a cortttactnr(s)
<br /> I liuennCd pursuant W the Contractor's License Law.)
<br /> ❑1 am exempt under Sec.__ _Y. — .—_.B&P.C.for this rcasun --
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<br /> Dale Ownes_�__�__�_�_�_—_—_--_� --- — --------�_�_�_�-_—
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<br /> w'oRlcr:xs'c11,mrl:,vs,vrlos nr:cl.nRA-rtn!v i
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<br /> I hereby atftrm that I have a cenifrcate of consent to self-insure.or a ceM.-w;oo cert.—wooor Workers'Compensation Insurance_or a certified copy thereof(Sec.3600,
<br /> Late.C). 1
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<br /> Exp DatC Company —__�--
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<br /> CI Certified copy is hereby furnished
<br /> k O Certified copy is filed with the County Building lnspecrion Dtvistrn
<br /> ' CERTIFICATE OF EXEMPTION FROM li'ORK.�:itS'C 0N1j'F.NSA'riloN uNsuRANcE
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<br /> (This section need not be completed,if the permit is for one hundred dollar:;rS ItYll or less,
<br /> I certify that in the performance of the work for which this permit is issucd I shat,riot employ any person in any manner stn as to become-uhjert tot he J
<br /> t Wo(kers'Cosnpcn,ation Laws of California. T
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<br /> NOTICE.TO APPLICANT:If,after making this C'enrficarc of 6Xcmpu01 ,cru should beco n-sub)4ci to the Workers'Compensation provisions of the
<br /> , Labor Codc,you must forthwith comply with such provisions nr this permit �htO be decried revoked.
<br /> CoVS'rRGCrtox LF:NIHNG AGENCY �}
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<br /> 1 herebv affirm that there is a arnsrtucuon Ending ageruy for the perfr rms•i::e o' r;te work for which this permit is issued(Sec 3(197,Civ.Ci. {
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<br /> L.ender'sNatrtr
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<br /> Lcorder'sAddress
<br /> DIVISION OF INDUSTRIAL SNI:VTY PERMIT CF:RTIF-ICAVON: JJf�
<br /> I herchy certify that nu excavattnn live 15)or more feet in depth rnro whi<h::pefi rn is required to dckcnrt,witi be mtkc in connection with work 1
<br /> authorized by the pencil.:ted that no txrtlding structure,,calfoldiug.(alsrwu:k.of tL-motition or dWriantirng thereof, will be nrure than thirty-six 06i fec: }
<br /> high. Whap.3.2,(irp 2. Art Z,Sec 341.Title g,C A.C.
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<br /> 0 As owner-builder.1 will not employ anyone ur do work which would regw7e a Laine from the Division of Industnat 5afety',as noted above.unless such 1
<br /> per.vun has a permit la du such work front the do istott. f
<br /> 1.7 Division of Im:ustrial Permit No.-—.—-_.—_—_ E
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<br /> 1 ceroty that I nave read this application and state that the alcove Information r.,correri. I agree to comply with all city and county ordmau"es and state laws `
<br /> relating ro well construction and or rewaEe systcrn construction,and herchy aulliorin:r.'pre<CntatrvCS of thlS City to enter upon the ahove-mentioned property it
<br /> for insPcxs:nn Purposes. !
<br /> } DttlC-- ----..Applicnnt—_Y �- ------- ----- -- ---- ---- . �.�_� I
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