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• Jos ADDRESS: / -�6-P /14R/l e e-,v Lad/ cA PERMIT P. LICENSED CONTRACTORS DECLARATION I hereby affirm Drat I am limned under the previsions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my rcamis LS in full force and Mfad. License#_cogew Expiration Date 8-30`-V Date Corltractor &D8 4AE" &L&,V5 f3,mp 56rjelre OWNER-BUILDER DECLARATION I hereby arfam that I am exempt hon the Contractors License Law for the following reason(section 7031.5,Business and Professions Code: Any city or county which requires a permit to construct,after,improve,demolish,or repair any structure,prior to its issuance, else requires the applicant for such permit to file a signed starement That he is licensed pursuant m the provisions of the Contractors Ucanse Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or that he is exempt henefran and the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500)): 13 I, as owner of the property, 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 appy to an Owner of property who builds or trnpmoves thereon,and who does such work himself or through his own employees,provided that such improvements are Trot intended or offered for sat& ff however, the building or improvement is sold within one year of completion,the owner-0uiiderwill have the burden of proving that he did net build or improve for the purpose of sale.) E3 I,as owner Of the popery.am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Coda(BBPC): The Contractors License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractors License Law.) O I am exempt under Section _, BBPC for this reason Date: Owner. WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Comipany O Certified copy is hereby furnished 13 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed H the permit is for one hundred dollars($100)or less) I certify that in the perfomance 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 Ai a//y7w, t/ &6 NOTICE TO APPLICANT: If.after making this Certificate of EmmPG,you Shea become subject to the Workers'Compensation Provisions attire Labor Code,you must%rff wimu comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I 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 Lender Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION O 1 hereby certify that no excavation five (5)Or more feet in depth into which a Penson is required to descend, Will be made in connection with work authorized by the permit,and Not no building structure,scaffolding,falsework,or derm ifion or dismantling thereof,well be more than thidy-six(36)feet high.(Chapter 32,Group 2,Article 2,Section 341,Title 8,California Aduninistralive Code). O As owner-builder,I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as noted above,unless such person has a perout to do such work from the division- [3 Division of Industrial Safety Permit# I certify that I have reed this appficabw and state limit the above information is curnea I agree in comply with all City and co Finances and stats laws rea8rg to well construction and or sewage system consoucmn,and hereby authorize rapresematives of this my to enter upon the above-nerr8oned property for inspection Purposes Date Applicant prof 17 tdAa7 LIC91SED CONTRACIme DECLA 11014