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<br /> j LICENSED CONTRACTORS DECLARATION
<br /> Y I I i-ew by amim+Thal I am{cer—d under the pronsims of Chapter 9(oornmenaon rig with Secti7000)d Divlsion 3 of the Business and
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<br /> .7 PTotess•ors(',ode and rtry licensea in full force and effect
<br /> ? License 0 764878 Expiration Date 6130^02I
<br /> Datef�r11,2ri19 Contractor C.xrjwoCurnNnit Im
<br /> OWNER-8UILDER DECLARATION
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<br /> � I heresy affirm that I am exempt from the Contractors License Law for the following reason(Section 7031 S,Business and Professions
<br /> i Crile Any city or county which requires a permit to construct,after,improve,demolish,or repair any stricture,poor to its Issuance,
<br /> -r also requires the app4rant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors
<br /> License Law(Chapter 9(comrnenong with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> �•s herefrom aril the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> lo a civil penalty of not more than five hundred dollars($500)):
<br /> ❑1,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 appy 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 vnthin one year of
<br /> completion.the Owner-builder YAM have the burden of proving that he did not build of improve for the purpose of sale.)
<br /> ❑I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> i Professions Code(BBPC). The Contractors License Law does not apply to an owner of property who builds or improves hereon,
<br /> v and who consVucls for such projects with a contractor(s)licensed pursuant to the Contractors License Law.)
<br /> ❑P am exempt under Section B&PC for this reason
<br /> Date:_ y ! `j Owner t4../ 77
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<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent lo self-insure or a C"late of Workers'Compensation Insurance,or a certified copy
<br /> thereof(Section 3800,Labor Code).
<br /> ExplrationDate 0701 0'0 Company ACE AMERICAN INSURANCE COMPANY(WLR C66038622)
<br /> ❑Certified copy is hereby furrkshed
<br /> ❑Certified copy is filed with the Enworvnental Heats Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need rot be ca^pleted if the permit IS for one hundred dollars(S 1001 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 subjed to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT Ir,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must forthwith comply with such provisions 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 3097,
<br /> Civil Code).
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby certify 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 dismantling
<br /> y thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California AdminsVative
<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 noted
<br /> t above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit M
<br /> I cent that I have read this application pplication and state that the above information is torted. I agree to comply with all city and county
<br /> ordinances and state Paws relating to well construction and or sewage system construction,and hereby auLhorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date 8;i 72019 Applicant bAvIrO SuLl"iv
<br /> I E.4D 4}Ct-007 LICENSED CONTRACTORS DECLARATION
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