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JOBADDRESS: ,J l XC Ct PERMIT#:
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter B(commencing with Section 7004olvision 3 ofthe Business and
<br /> Professions Code and my license Is fup force and effect.--License# (1-C /— ration D
<br /> Date 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 Professions
<br /> Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any 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 Lew(Chapter 9(commencing with Section 7000)of Division s 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 /> ❑1,as owner of the properly,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 contractors License Law does not apply to an
<br /> owner of properly 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-builder 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,Tan 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 contractor(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,ora o9dWicate of Workers'Compensation Insurance,or a
<br /> certified copy thereof( ectl n 3800,Labor Code)_ ' v
<br /> Expiration Date " / Company ' r"
<br /> ❑Certified copy Is hereby furnished
<br /> Certified copy Is filed with the Environmental Health Department
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<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> .(This section need not be completed If the Permit Is for one hundred dollars($100)or less)
<br /> 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
<br /> as to become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT:It,after making this Certificate of Fxemptlon,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permit shad 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 /> ❑ 1 hereby certify that no excavation live (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,faksework,or demolition or dismantling
<br /> thereof,will be mote than thirty-six(38)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,jlta-4L, Adminlskative
<br /> Code). ,\
<br /> ❑As owner-builder,1 will not employ anyone to do work which would require a permit from the D41on of Indu'Adal Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Sarety Permit X
<br /> I certify that I have read this application and state that the above information is correct. I agree, comply with allcity nd county
<br /> ordinances and stat laws retailing to well construction and of sewage system consiryclion,aro here authorize represen fives of this
<br /> county to ent r upo the alzDve menticned property for Inspection purposes.
<br /> Date 1\ Applicant /
<br /> END 4y0T
<br /> 11011907L1CEZ79 CON TRAC FOR DECLARATION
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