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JOBADORESS: fpli�{tiK�/Tl ll�/�/l PEA.-
<br /> LICENSED
<br /> EA:LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect. //
<br /> License# 0 S-7 9.13 3, 2 (P Expiration Date 6/ 30A2COL
<br /> Date ,A2 V,AM(e Contractor 1 Dc_ X�Ib'/Q."I'bl-. -0- Q a 11 S
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Cade: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)):
<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
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. If,however, the building or improvement is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> E3 1,as owner of the property,an exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a connacmr(s)licensed pursuant to the Contractor's License Law.)
<br /> O 1 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 certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Dat M7 Company I.Y *~' D I o ra+-'oo, 4- We-1 I s
<br /> 0 Certified copy is hereby famished
<br /> WCertified copy is filed with the Environmental Health Department Cay 1-0 S G)
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This Section need not be completed if the permit is for one hundred dollars 5100)or less)
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to
<br /> become subject to the Workers'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'
<br /> Compensation provisions of the Labor Code,you most forthwith comply with such previsions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Leader's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 61 hereby unity that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismanding
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative
<br /> Code).
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> O Division of Industrial Safety Permit 4
<br /> I certify than I have read this application and state that the above information is correct. 1 agree to comply with all city and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authoorrizeerepresentatives of this
<br /> county to enter upon mg above-mentioned property for inspection purposes.2//
<br /> Date 3 23/,�aob Applic
<br /> E4�43-02-1qJ LICENSED CONTRACTORS DECLARATION
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