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(__.) I am exempt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: http://www.leginfo.ca.gov/calaw.html. Property Owner or Authorized Agent signature Date #3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST, AND ATTORNEY'S FEES. WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: U I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. U I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy No Expiration Date Name of Agent Tel No U 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 become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury 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 and Address #4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to each of the following: I am (_) a California licensed contractor or (_) the property owner* or (_J authorized to act on the property owner's behalf**. All existing survey monuments are to be preserved per California Senate Bill 1467. It is the applicant's responsibility to ensure that all monuments are properly protected and/or perpetuated. If any of the monuments are to be disturbed or are near the area of construction, it is the applicants responsibility to hire a licensed surveyor to confirm that the monument(s) has been protected and/or perpetuated and that the appropriate documentation has been recorded. I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes, *requires separate verification form California Licensed Contractor, Property Owner*or Authorized Agent**: **requires separate authorization form Signature Date J:\Community Development\Building Inspection\Forms\Permits\Permit Application Current wLandscape.doc2 of 2