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JOB A DRESS: PERMIT#:
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bu..utess
<br />and Professions Code and my license is in full force and effect.
<br />License #
<br />Date
<br />Expiration Date
<br />Contractor
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br />Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to
<br />its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br />Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he
<br />is exempt herefrom and the basis for the alleged exemption. Any violation of Section 703I.5 by any applicant for a permit subjects
<br />the applicant to a civil penalty of not more than five hundred dollars ($500));
<br />❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br />intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner
<br />of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br />improvements are not intended or offered for sale. If, however, the building nr improvement is sold within one year of completion,
<br />the owner -builder will have the burden of, proving that he did not build or improve for the purpose of sale)
<br />Q 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br />and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br />and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law,)
<br />13 I am exempt under Section __, B&PC for this reason
<br />Date: Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified
<br />copy thereof (Section 3800, Labor Code),
<br />Expiration.Date
<br />Company
<br />Q Certified copy is hereby furnished
<br />C] Certified copy is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS, COMPENSATION INSURANCE
<br />(This section need not be completed f the pertnit is for one hundred dollars M100 or es
<br />I certify that in the performance of fle work for which this pennit is issued, I shall not employ anyvson in any manner so as to
<br />become subji'.' f t6the'Worker A Co alien tart's fflifamia: _" ' ' ^.a\
<br />Dates i Applicant
<br />NOTICE, TO APPLICANT_ Ifer snaking .this Certificate of Exemption, you should become ,jubject to the Workers'
<br />Compensation provisions of the Lab r Code, you must forthwith comply with such provisions or this permit 51411l be deemed revoked.
<br />{ CONSTRUCTION LENDING AGENCY `
<br />r
<br />I hereby affirm that there is.a construction lending'age icy for'the performance 6f the work for whi.^.h this permit is issued (Section
<br />3097, Civil Code). I
<br />a
<br />Lender's Namet ~ ` r
<br />Lender' Address r -
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br />O I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in
<br />connection with work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling
<br />thereof, will be more than thirty-six (36) feet high, (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br />Code).
<br />❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as
<br />noted above, unless such person has a permit to do such work from the division.
<br />❑ Division of Industrial Safety Permit
<br />I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county
<br />ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon the above-mentioned property for inspection purposes.
<br />Date Applicant
<br />MID 43-024W MASTER Water well Permit Contractor Declamction
<br />12(5/2002
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