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JOB ADDRESS: 1)ERMIT If:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 herehy nfrom Rrnt I nm I'censed under the rimis'.ons of Clup!er 0(cenimeecing vMh SecCon 7030)of Dwislon 3 of Ilia Business and
<br /> ProfmVris Code and my I erns,)is in full fo(co and effect
<br /> LiconsoI/_ 1 It��h (` ExpirationDolo
<br /> Dalo i.� '7. l`\ ?) Contractor 1r''l \ c�\ t'vl l\ 1���`\\\(4
<br /> OW14ER•BUILOER DECLARATION
<br /> 1 hereby alkni that I em exempt from rho Conunctor's Ucanso Low for the fo1ov.ing reason(SecSon 7031.5,Dus'noss ani Prcloss!ons
<br /> Code: Any qty of county v,hkh requires n permit to constfucl,aiter,Improve,demolish,or lop,,:(any s7ucluro,prior to its Issuance,
<br /> also fequ'fes the oppl:cant for such perm':!to Vo a signed statement that he Is licensed pufsuant to tiro pray sions of the Contractor's
<br /> License Law(Chapter 0(commencing vilh Secl'on 7000)of DWislon 3 of the Business end Professions Cain)or that ho Is exearpt
<br /> herofiom and the bass for tho alleged oxemp5oo. An/Yetation of Section 7071.5 by any appt.canl for a pormil sub;ecis the appl cant
<br /> to a cibl penalty of no:rno(o,than Olt hundred dollars(5500)):
<br /> O I,as corner of Ilia properly,or my employees Will wagos ns Ihelr so'o compensal-on,v.-Il do Oro v.ork,mid the slrucluro Is not
<br /> Intended or offered for sale(Section 7044,Business and Professions Code:This cenUaciVs License Lou does not appy to an
<br /> owner of property s•rho bui'ds at Improves thereon,find who does such v;ork himself or through his oem employees,provided that
<br /> such imprown,onis aro not Intended or offered for sale. 11, hvvovef, the bu'!din.)of Impwtemenl Is sold within one yeer of
<br /> cor iftlion,the o.ner•bvl'der sill have,the burden of proving that he d'd not buad or Improvo for Oro purpose of solo)
<br /> ❑I,as o.-met of(Ito property,om oxclusivaly convncting Will I ceased cnnhactrxs to constarl thn project(Section 7044,Bus'ness and
<br /> Professions Code(DBPC): The Contractors Llconso Lav+does not appy to on ovmer of property svho tui'ds of Impro'+es hereon,
<br /> and vtro constructs(at such pro;ecis%,41h a eontraclor(s)licensed pursuant(o Ilia Conlfaclors License Law)
<br /> ❑I nm oxompt I:ndor Section __ Bt.PC(or This foason
<br /> Date:
<br /> WORKERS'COh1PENSATION DECLARATION
<br /> I hereby alfmi that I have a certificate of consent to self-Insure or a cerhfcale of Workets'Compensation Insurance,or a
<br /> eelliffed copy thereof(Section 3800.Labor Ccde). `
<br /> Expiration D,1(0_-** (� �� Company 0'\\'\
<br /> ❑Certified copy is hereby furnished
<br /> Q Certified copy Is filed arth Ilse Environmental Henlih Depaflmont
<br /> CFRTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> 7i11S section need not be completed if lho 0ermil Is for ono hwxJfOtl do_Imrs-(i10Q)_0jless
<br /> certify that ht the performance of lite v;oik for vAtich Ihis permit Is issued,I shall not employ any person In any manner so
<br /> as to become subject to the Workers'Compensalion Laws of Colifohbla.
<br /> Delo:_— - ... Applicant_ --_—__--
<br /> NOTICE TO APPLICANT:If,after macnp this CottAcalo of Exempl'on,you slou'd becomo sublecl to Ute Workers'Conipensation
<br /> provisions of Ilia Labor Code,you must roittnvilh comply v.;lh such p:ovisiovs or this permit shaft be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby offirfn 111111110/0 Is a construction lending agency for Iho performance Of 1110 vrmk for Witch this permit Is Issued
<br /> (Section 3097,Civil Code).
<br /> Londot's Noma
<br /> Londor'Addross ---
<br /> DIVISION OF INDUSTRIAL.SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby certify that no excavaton rive(5)or mono feet In depth Into Which n person Is fequ'red to descend,sill be made In
<br /> connection vitt walk authorized by the perms,and that no bu.!ding slructuro,scafro'ding,fa3ev,ark,or domo!rtion or disnwn!'�ng
<br /> thereof,will be mono than OO tpslx(30)feet h'gh.(Chap!cr 3.2,Croup 2,Arl'iclo 2,Sec('cn 341,T Jo 0,Cal.roWn Adri nistaalivo
<br /> Coda).
<br /> CI As O.wer•buder,I v.*.It not emp:oy anyone to do work%Okh v.,ou:d requ:o a permit rrun Ilia D,vision of Industrial Safely,as noted
<br /> above,unless such parson has a pernul to do such eror'..from Ilia dsis!on
<br /> ❑Divislon of Industrial Safoty Permit if
<br /> cattily that 1 have read this opp'Ietlion and stale that the obovo IMormaTon Is correct.I ngreo to comp:y with all city and county
<br /> ord:nancos and stale laws iolafrg to writ eonslructJon and or so--ago system construction,and hereby nutlto(izo foprosonlakes of this
<br /> 03unly to enter upon Ilia above.menGoncd property for Inspecl:on purposes
<br /> Dale=•l ":) \�l Applicant (s.t-'To 1rr ��, �J ZL�t';(� ll•i1_.'[
<br /> UID 43 ei
<br /> t ucLtrseOColl uuCTOROreuRsnar
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