Laserfiche WebLink
• ` 1 <br /> JOB ADDRESS: I INLC4N G6 Nr (L <br /> 6 -FE rwrD 645rj 19 GIFiG 'IVE'PERMIT#: <br /> LIC <br /> I hereby affirm that I am licensed under the proENo sO f c ap RACT <br /> Professions Code and my license is in full once and effect License <br /> DE 9LAhRAT�ION 7000)of Division 3 of the Business and <br /> License# 913194 <br /> ExPira <br /> 17 <br /> Date 6/15/15 Contractor Jason Brown t(CFO)behaif 4/of�C/onfluence Environmental <br /> OWNER-BUILDER DECLARATION <br /> I hereby affirm that I am exempt from the ConNacor's License Law for the following reason(Section 7031.5,Business and Professions <br /> Code: Any city or county which requires a permit o ConsWct,alter,improve,demolish,or repair any structure,prior to its issuance, <br /> also requires the applicant or such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's <br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 Of the Business and Professions Code)or that he is exempt <br /> herefrom and the fasts or the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant <br /> o a civil penalty of not more than five hundred dollars(y500)): <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 peered 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 Nat he did not build or Improve or the purpose of sale.) <br /> ❑1,as owner of the property,am exclusively Contracting with licensed Contractors to Construct the pro)ect(Section 7044,Business and <br /> Professions Codeand who constmcisBfor such Projects with aresonntracto�(s)licensed putapply to an owner Of rsuant o the Contractors License Law.) <br /> P P rty who builds or improves hereon, <br /> 131 am exempt under Section <br /> BBPC orchis reason <br /> Date <br /> 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 <br /> certified copy thereof(Section 3800,Labor Code). <br /> Expiration Date 2/1/16 <br /> ---�_ Company State Compensation Insurance Fund <br /> 18 Certified copy is hereby furnished <br /> ❑Certified copy is filed with the Environmental Health Department <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> This section need not be com leted if the Permit is for one hundred dollars 100 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 <br /> as to become subject to the Workers'Compensation Laws of California. <br /> Date: <br /> 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 Coda,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 <br /> (Section 3097,Civil Code). <br /> Lender's Name <br /> Lender'Address <br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br /> 13 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 structurescaffolding,falsework,or demolition or dismantling <br /> thereof,will be more than thirty-six(36)feet high. (Chapter 3.2, Group 2,ArtiGe 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 noted <br /> above,unless such person has a permit to do such work from the division. <br /> ❑Division of Industrial Safety Permit# <br /> I certify that I have read this application and state that the above information is Correct. I agree to C0mPIY with city and county <br /> ordinances and state laws relating to well construction and or sewage system Co u n,and hereby authorize reprelse atives of this <br /> County to enter upon the above-mentioned property for inspection purposes. <br /> Date 6/15/15 <br /> Applicant <br /> EHD43-07 <br /> 1015107 LICENSED CONTRACTOR DECLARATION <br />