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JOS ADDRESS: _—4 P ERM11'#: ) LICENSED CONTRAC FORS DECLARATION I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License#_ Expiration Date Date Contractor I OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License L.aw for the following reason (Section 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 such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500)): ❑I,as owner of the property, or my employees with wages as their sole co mpensation, will do the work,and the structure is not intended or offered for sale(Section 7014.Business and Professions Code:T e contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees,provided that such improvements are not intended or ofTerad for sale. If,however,the building or improvement is sold within one year of completion, the owner-builder will have the burden of'proving that he did not build or improve for the purpose of sale.) I O I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): 'Che Contractor's License Law docs not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractur(s)licensed pursuant to the Contractor's License Law.) I am exempt under Section_ _i B&PC.for this reason Date: Owner i I WORKERS'COMPENSATION DECLARATION 1 I hereby affirm that I have a certificate of consent to self-insure,or r certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company___ 13 Certified copy is hereby furnished O Certified copy is filed with the Environmental Health Department I CERTIFICATE OF EXEmpTION FRO.M WORKERS'COMPENSATION INSURANCE t tThis section need not be comoletgg if�the•p_. t is for one hundred dollars(s 100 or less) I, I certify that in the performance of the work ibr which this permit is issued,I sball not employ any person in any manner so as to II become subject to the Workers'Compensation Laws of California. 1 4 Date: Applicant _� 1 J NOTICE TO APPLICANT: If, after making this Cerlificatr of Exemption, you should become'subjcet to the Workers' l ;l;ompensation provisions of the Labor Code,you must forthwith cnmply with such provisions or this permit shall be deemed revoked, CONSTRUCTION L!!SDING AGENCY I hereby affirm that there is a construction lending.agency,for the performance of the work fbr which this .permit is issued(Section3097,Civil Code). i Lender's Name I Lender'Address i DIVISION OF INDUSTRIAI.SAFETY PERMIT CERTICATION ❑ I hereby certify that no excavation Live(5)or more feet in depth into which a person is required to descend, will be made in connection with work authorized by the permit,and that no building structure,scaffolding, falscwork,or demolition or dismantling thereof;will be mrre than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative Code). 13 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. rI ❑Division of Industrial Safety Permit K I — i I certify that l have read this application and state that the above information is correct. I agree to comply with all city and county wage system construction,and hereby authorize representatives of this ordinances and state laws relating to well construction and or se + county to enter upon the above-mentioned property for inspection purposes. Date Applicant +jI' E140 43-02-007 MASTER Water well Permit Cont wtor Dectaraction ? 1175.+2002