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JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is In full force and effect.
<br /> License# 4t .,... Expiration Date
<br /> Date �- �—�+�t7 Contractor AATI�_.% 4Lt
<br /> OWNER-BUILDER DECLARATION ~
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,
<br /> also requires the applicant for 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 basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars($500)):
<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 offered 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 that he did not build or 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 /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improvers hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑I am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure ora certificate of Workers'Compensation Insurance,ora certified copy
<br /> thereof(Section 3800,Labor Code). ..-� �
<br /> Expiration Date Zc,� Company /J o �
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<br /> 0 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 completed 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 as to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: 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 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 /> �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
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high. (Chapter 3.2,Group 2,Article 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 /> 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and County
<br /> ordinances and state laws relating to well construction and or sewage system construGton,and hereby authorize representatives of this
<br /> county to enter up the above-mentioned property for inspection purposes.
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<br /> Date 3 S�ld Ze) Applicant
<br /> EHO 43.02.007 LICENSED CONTRACTORS DECLARATION
<br /> B-2609
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