|
JOB ADDRESS: 120D I I WM Q -11 �y f, Cut -11C PEwarr#:
<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 Business and
<br />Professions Code and my license Is In full force and effect.
<br />License# +65)W5 _ Expiration Date e)11-i1)2-uIle�
<br />Data 900121:>13 Contractor1�� r,c
<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 Professions
<br />Code: Any city of county which requires a permit to construct, alter, Improve, demolish, or repair arty structure, prior to Its Issuance,
<br />also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's
<br />License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
<br />herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br />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
<br />owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that
<br />such Improvements are not intended or offered for sale, If, however, the building or Improvement Is sold within one year of
<br />completion, the owner-bullder will have the burden of proving that he did not build or Improve for the purpose of sale.)
<br />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br />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 contraclor(s) licensed pursuant to the Contractor's License Law.)
<br />❑ 1 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
<br />certified copy thereof (Section 31300, Labor Code). 1
<br />Expiration Dat / ?-0// Company/
<br />13 Certified copy Is hereby furnished W 4! 0
<br />,q'Certified copy is filed with the Environmental Health Department
<br />i
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This section need not be completed if th_e_pegpllt is for one. hundred dollars . 100 .or toss
<br />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
<br />as to become subject to the Workers' Compensation Laws of California,
<br />Date:
<br />Applicant
<br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br />provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued
<br />(Section 3097, Civil Code).
<br />Lender's Name
<br />Lender' Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />t lj hereby certify that no excavation five (5) or more feet In dupth Into which a person Is required to descend, will be made In
<br />connection with work authorizoel by the permit, and that no building stn. chlre, 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 a. California Adminintrative
<br />Code).
<br />❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted
<br />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 construcllon and or sewage system construction, and h eby authqF0 rqt)resentativos of this
<br />county to enter upon the above-mentloned property for Inspection purposes.
<br />Date o I 2 12D1-:� Applicant —�---
<br />EHD 43-07 LICENSED CONTRACTOR DECLARATION
<br />10/6/07
<br />
|