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�6-15- fC/AU PI.� egT7� PERMITM JOB AOORESS: c LICENSED CONTRACTORS 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 � � 7 Expiration Date l /30 Zm/L License Date Z lot Contra ctor OWNER-BUILDER DECLARATION I hereby affirm that am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions Code: Any cdy or county which requires a permit to construct alteq improve,demolish,or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signetl statement that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of ONislon 3 of the Business and Professions Cotle)or that he is exempt herefmm and the hzsis 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($500)): , ❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale(Section 7044, Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,antl who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If, however, the huilding 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 forthe purpose of sale.) O I,as owner of the property,am exclusively Contracting with licensed contactors to Construct the project(Section 7044,Business and Professions Code(B&PC): The Contactors License Law does not apply to an owner of properly who builds or improves hereon, and who Constructs for such projects with a contactor(s)licensed pursuant to the Contractors License Law.) ❑I am exempt under Section , B&PC for this reason Date: Owner: WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a Certificate of consent to self-insure or a Certificate of Workers'Compensation Insurance,or a certified Copy thereof(Section 3800,Labor Code). Expiration Date Company O Certified copy is hereby furnished VCertified Copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be Completed if the permit is for one hundred dollars($100)or less 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 become subject to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption.you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith Comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affil that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION I hereby certify that no excavation five (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,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Tite 8,California Administrative Code). 13aso weer uli such pewill rnot hasemploy a permit to do such work from would he di require a permit from the Division of Industrial Safety,as noted 13 Division of Indusbial Safety Permit# I certify that I have read this application and state that the above Information is correct I agree to comply with all Gly and county ordinances and state laws relating to well Construction and or sewage system construction,arld hereby authorize rep enta6ves of this County to e/nJer up9p the above-menfioned property for inspection purposes. Date Applicant LICENSED CON CTOR DECI t TION ERD a 07 10r&m