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JOBADDRESSr p/ I x PER..#: LICENSED CONTRACTORS DECLARATION I hereby affirm that i am licensed under the provisions of Chaotar s(commencing with Section 7000)of Division 3 of the Business and Protesslons Code and my license Is In full fore and effect, License# Expiration Data Date Contractor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business end Professions Cade: Any city or county which requires a permit to construct,altar,improve,demolish,or repair any structure,prior to its issuance, also requires the applicant for such pemtit to file a signed statement that.he is Gccnsod pursuant to the provisions of tie Contractors License Law(Chapter 9(cornmercing wilt:Section 7000)of Division 3 of the Business and Professions Cade)or that be is 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 then five hundred dollars($500)): ❑I,as owner of the property,or my employees with wagas as their sole compensation,win do the work,and the structure is not intended or offered for sale(Section 7044, Business and Pions Code:The contractees License Law does not apply to an owner of property who builds or improves thereon.,and who does such work himself or through his own employees,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 ovmer-builderwill have the burden of proving That he did net build or improve for tie purpose of sale.) 11 1,as owner of the property,am exclusively contrar:ting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&aC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constn cls for such projects with a contractor(s)licensed pursuant to the Contractors License Law.) 01 air:exempt under Section WC far this reason Date: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I haves celtirrcafe of consent to ser insure ora curate of Workers'Compensation[nsuranca,or a oerged copy thereof(Section$800,Labor Code). Expiration Date C—pant' ❑Certffed copy is hereby furnished M CertiSed copy is filed v&"i the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be corn [etas if the pemut is for one hundred dollars($1 go)or less) I certify that in the perfomtance of the work forwhich this permit is issued,Ishan 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 Certificata of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must fxthwith comply with such provisions or this permitshall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a conszucticn lending agency for tie perfomnnce of the work for which this permit is issued(Section 3097, Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION p 1 hereby certify that no excavation Sva(5) or more feet in depth into which a person is required to descend,will be made in connec5on vAh won.,authorized by the permit,and=hat no building structure,scarTo[ding,fa[sework,or demolition or dismantling thereof,NN[be more than thirty-six(36)feet high.(Chapter 32,Group Z Article Z Section 341,Title 8,Callomia Administrative Code), Cil As owner-builder,I will not employ anyone to do work which would requite a permit from the Division of Industrial Safety,as noted aboye,unless such person has a perm3 to do such work from the division. 0 Division of industrial Safety Permit# I certify that I have read this application and state that the above information Is correct 1 agree to comply with all city and count' ordinances and state laws relating to well construction and or sewage system constructors,and hereby authorize representatives or this county to enter upon the above-mentioned property for inspection purpases. Data Applicant UCE14SED C0WRAcroRs DECwuTiory E iD 4302-7 6-26-0