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JDs ftom.24 I k (A PU PERMT#: LICENSED CONTRACTORS DECLARATION I hereby affimr that I em licensed under the provisions of Chapter e p o arcing with Section 7000)of Division 3 of the Buslness and Professions Code and 'frc�ern its irn II force and effect License r1Iq D1 Y Expi -tel Data '57L'119– Data11224 L� Contractor OWNER-BUIL R DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following reason(Section 70315,Business and Professions Code: Any cry or county which requires a permit to construct,Sher,improve,demolish,or repair any structure,poor to its Issuance, also requires the applicant for such permit to file a signed statement that he is licensed pureuant to the provisions of the Contractors License Law(Chapter 9(commenting with Section 7000)of Division 3 of the Business and Professors Cade)or that he u exempt herefrom and the basis 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)): E3 I,as owner of the property,or my employees with wages as their sola compensation,will do the work,and the structure is not intended or offered for sale(Section 7044,Business and professions Code:The contractors License Lew does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employem provided that such Improvements are not intended or offered for sale. If,however, the building 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 for the purpose of sale.) ,r .as corner of the property,em exclusively contracting with licensed contractors to construct the pmlect(Section 7044,Business and Professions Code(BBPC): The Contractors License Law does not appy to an owner of property who builds or Improves hereon, and who constructs for soon projects with a contractor(s)licensed pursuant to the Contractors License Law.) O 1 em exempt under Section , B&PC for this reason Date- J�.� '7 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 themro�f jgI e�ctipn,3800,labor Code). Expiration Date Company O Certified copy is hereby fumisfumished� QJ XCertified copy is filed with the Environmental Health Department CERTIFICATE OF FXEMPT(ON FROM WORKERS'COMPENSATION INSURANCE Ion need not be completed if the permit's for one hundred dollars($1001 or less) I certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws f Califo ia_ DSta: a�.–�� Applicant— NOTICE TO APPLICANT:If,after making this Certificate of mpbm.you should become subject to the Yorkers Compensation provisions of the Labor Code,you mustforthwith comply wdh such provisions Orthis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY hereby affirm 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 Lendoe Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION XI 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.faisawork,or demolition or dismantling thereof,will be mora than thiry-sbr(36)feet high.(Chaptar 3.2,Group 2,Article 2.Section 341,Title 8,California Adminrstrafwe Code). As owner builder,I will not employ anyone to do work which would require a Permit from lite Division of IndustraI Safety.as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Permit# I certify that I have read this application and state that the some information is erect I agree to comply with all city and county ordinances and state laws retailing to.11 wir sWction and or sewage system consWcLon,and hereby authorize reprosentalives of this county to enter upon the above-mentioned property for inspection purposes. Date_—��2 3-1--Z APpiicar(t. I