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JOB ADDRESS: PERMIT 8: 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*_ zito- --------.__-----_–____ Expiration Date Date ( 7 J) _ Contractor 11111 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and 0,rofessrons Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to it issuance, also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the ntractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that h is exempt herefrom and the basis for the alleged exemption Any violation of Section 7031.5 by any applicant for a permit subjectftapplicant to a civil penalty of not more than five hundred dollars(5500)) i 0 I,as owner of the property,or my employees with wages as their sole compensation,will do the vrark,and the s1r re 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,p,•JYNided that such improvements are not intended or offered for sale. 4, however, the building or improvement Is sold within ripe year of completion,the owner-builder wilt have the burden of proving that he did not build or improve for the purpose of sale.) ` O 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,B�iness and Professions Code(BBPC). The Contractor's License Law does not apply to an owner of property who builds or impus hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) ❑1 am exempt under Section BBPC for this reason Date:.--------------___._.__.__.-._----- Owner----- ----_.------_.—._--- ---------- WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-Insure or a wrtiBcate of Workers Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code) ,��-- Expiration Date Company BCertified copy is hereby furnished O Certified copy is filed with the Environmental Health Departmerd CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed i(the oernit is for one hundred dollars(4100)or less) I certify that in the performance of the work for which this permit is Issued,I shall not emDioy 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 vnth such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agoncy for the performance of the work for which this permit Is issued(Section 3091, Cvil Code). Lenders Name __._l•___ _ Lender's Address OMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION O 1 hereby certify that no excavation five(5)or more feet In depth Into which a person is required to descend,wit be made In connection with work authorizeil by the permit,and that no building structure,scaffolding,falsewoN or demolition or dismantling [hereof,will be more than thirty-six(36)feet high (Chapter 3-2,Group 2,Article 2,Section 341,Tale 8,California Administrative Code), 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. O Division of Industrial Safety Permit# I certify that I have read this application and stale that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection'Purposes Date Applicant ._.. END 43 02 DD? UCENSED CAMRACTORS DECLARATION fi 2e(W