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`- JoBADDRESS: C yNN �4�CIr��iur /�(/)/ PERMITS
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby am=that I nm licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is
<br /> in full force end eaect..o
<br /> License# r J X 7 �+ Expiration Date 16
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<br /> Date -��Q Contractor YISCH TinVL✓&fk MQ fA -le-A',
<br /> OWNER-BUILDER DECLARATION
<br /> 1 hereby afRmn that I am exempt from the Connector's License Law for the following reason(Section 7031.5,Business and Professions Code: Any city or only which
<br /> requires a permit o construct,alter,improve,demolish,or repair any sauctme,prior to its issuance,also requires the applicant for such permit to file a signed statement that
<br /> he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade)
<br /> or that he is exempt bombast 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
<br /> of not more than five hundred dollars($500)):
<br /> 01,as owner of the property,or my employees with wages as their sale compensation,will do the work,and the structure is not intended or offered for sale(Section 7044,
<br /> Business and Professions Code:The contractor's License Law does not apply told owner of property who builds or improves thereon,and who does such work himself or
<br /> through his own employees,provided that such improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of
<br /> completion,the owntt-buildtt will have the burden ofpmving that he did not build or improve for the purpose ofsale.)
<br /> 13 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,and
<br /> who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> 0 I am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers Compensation Insurance,or a terrified copy thereof(Section 3800,Labor
<br /> Code). /�
<br /> Expiration Date Y.—Qy Company s"7f' (?/7MV_Jis,rUnd
<br /> 13 Certified copy is hereby furnished
<br /> al'Ce tified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed ifthe pound is for one hundred dollar,5100)or loss)
<br /> 1 certify that in the performance of the work for which this permit is issued,)shall not employ any person in any manner so as to become subject to the Workers'
<br /> Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you most forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> el hereby certify that no excavation five(5)or more feel in depth into which a person is required to descend,will be made in connection with work authorized by the
<br /> permit,and that no building structure,soa folding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Ankle
<br /> 2,Section 341,Title 8,California Administrative Code).
<br /> O As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> 1 certify that 1 have read this applicmimt and abate that the above information is correct 1 agree to comply with all city end county ordinances and state law,
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property
<br /> for Inspection purposes.
<br /> Date �'�7 '�0� Applicant
<br /> EHD 43-02-007 Licensed Comracurs Dedaratloada,
<br /> 8/202003
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