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Sot ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License# Expiration Date Date Contractor sw .f fie.- ,rs OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 70315,Business and Pro&ssions Code. Arty city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant fcr such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Divisiem 3 of the Business and;Professions Code) or that he 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 mote than five hundred dollars(5500)): O 1,as owner of the property,or my employees with wags 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 contractor's License Law does not apply to an owner of property who builds it improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. lf,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 pttupose of sale.) ❑ I,as owner of the property,am exclusively contracting with licensed contractor,to construct the project(Section 7044,Business and Professions Code (B&PC): The Contractor's 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 Contractor's License Law.) O I am exempt under Section B&PC for this teason_ Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm.that I have a certificate of consent to self insure,or a eenifieate of Workers'Campensati m Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company 13 Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be cormletied if thKW=g for one hundred dollars($100)or kss) 1 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 Worlom' Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performa of the work for which this permit is issued(Section 3097,Civil Code). �,L +�s Name —" pr' �vwapv" •� L•f Lender'Address See— Qltie.