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JOB ADDRESS:_ _ PERMIT#: -" LICENSED CONTRACTORS DECLARATION 1 hereby affiry that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Cede, and my licenac is in full force and effect, License q Exp.:Dalc Date ^Contractor_ OWNER-BUILDER DECLARATION I hereby affirm that I am excrapt from the Contractor's License Low for the following reason(Sec.7031.5.Business and Profcasions Code; Any city or county which requiras a permit to construct,alter,improve,demolish,of repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he;s licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(conuTttncing with Section 7000)of Division 3 of the Business and Pro`essions Cade)or that he is exempt hcrcfrom and the basis for the alleged exemption. Any violation of Scetion 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mom than five hundred dollars ($500)): 111,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 fur sale (Sec.7044,Business and Professions Code:The Contractors license Law does not apply to an owner of property who builds to improves thereon,and who docs 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 owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑I,as owner of the property.am exclusively contracting with licensed contractors to constnret the pmject(Sec.7044,Business and Profession Code:The Contractor's License UW does not apply to an owner of property whn builds or improves thereon,and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑1 am exempt under Sec._ ,B&P.C.for this reason Date - Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a ceitifulate of Workers'Compertsatsnt Insurance,or a certified copy thereof(Sec.38110, Lab.C). i Exp.Date Company _ ❑Certified copy is hereby furnished ❑Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE j (This section aced not be completed,if the permit is for one ticndred dollars($100)or less/ I certify that in the performance of the work for which this p-:rmit is issued,I shall nor employ any person in any manner so as to become subject tot he Workers'Compensation Laws of California Date Applicant _ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become suhjwr to the Workers'Compensation provisions of the Labor Code,you most foahw ith comply with suet,provisions or this permit shall be deemed revoked. CONSTRUCTION LENDINC AGENCY I hereby&[firm that there is a construction lending agency for the performance of the work for which-this permit is issued(Sec.3097,Civ.C). Lender's Name— _ I - Isnder's Address DINTSION OF INDUSTRIAL SAFETY PERMrr CERTIFICATION: - I ❑1 hereby certify that no excavation five(5)or mote feet in depth into which a person is required to descend,will be make in connection with work authorized by the permit.and that no building structure,scaffolding,falsewnik.or demolition or dismantling thereof,will be more than thirty-.six(36)feet high. (Chap.3.2,Orp 2,Ast 2,See 341,Title S.C.A.C.). - ❑As owner-builder.I will not employ anyone in do work which would require a permit from the Division of Industrial Safely,u noted above,unless such person has apermit to do such work ftum the division. - t ❑Division of ludustrial Permit No, I certify that I have read this application and state that the above information is correct. I agree io comply with all city and county ordinances and state laws relating to wcH construction and or sewage system construction,and hereby authoriic tepresenraCmes of this city to enter upon rhe above-mentioned property for inspect;on purposes. Dole- Applicant _