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1 JOB ADDRESS: •• 2 1 O PERMIT#: I LICENSED N CTORS D TION I hereby affirm that I am licensed under the provisions of ler 9(comme i g h -of Division 3 of the Business and Professions Code and mlitcennse is in full force and effect License# lX- i -on Date 51 Z02:2— Date 02 2Date Contractor Don Ee6m &M0 VVV OWN ER-BU ILDE CLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions Code Any city or county which requires a permit to construct, alter. Improve demolish,or repair any structure. prior to its Issuance. also requires the applicant for 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 Division 3 of the Business and Professions Code)or that he is exempt herelrom 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 more than five hundred dollars(S500)) ❑ 1, 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 for sale(Section 7044. Business and Professions Code. The contractor's License Law does not apply to an owner of property who builds or improves thereon.and who does 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 construct the project(Section 7044.Business and Professions Code(BBPC): 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 Contractors License Law.) 1:11 am exempt under Section . BBPC for this reason Date: Owner WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to sell-insure or a certificate of WorkersCompensation Insurance or a certified copy (hereof(Section 3800, abor Code). Expiration Date Company ❑/Certified copy is hereby furnished 6d Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit Is for one hundred dollars($100)or less) 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 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 I hereby affirm 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 Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION Ihereby certify that no excavation five (5) or more feet in depth Into which a person is regwred de end, will be made In connection with work authorized by the permit,and that no building structure. sca .ling. falsew o olition or dismantling thereof.will be more than thirty-six(36)feet high (Chapter 3.2. Group 2.An Section 341' tie . lifornia Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a er it Om the Di Sion f n ustrial Safety as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Permit# I certify that I have read this application and state that the above Information rrect. I a of t y with and county ordinances and state laws relating to well Construction and or sewage system ns ction, e( a presentatives of this county to e ter upolthe a/pQ)ve mentionetl property for inspection purposes. Date (} � I �V APPIIc t i —r EHO 41-02-007 LICENSED CONTRACTORS DECLARATION 62609