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JOBADDRESS' T ► J'�I ` /1\ �`C� ��,t PEf2MIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 31of the Business and
<br /> Professions Code and my license Is full force and affect. I
<br /> License# 1/��� Ex��ration Dat
<br /> Date 1 ContractorL�
<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,after,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 Law(Chapter 9(commencing with Section 7000)of Division 3 or 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($5D0)):
<br /> d I,as owner or 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 Prolessdo03 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 /> completlon,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,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 contractor(s)licensed pursuant to the Contractor's License Law,)
<br /> ❑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 ' tale of Norkers'Compensation Insurance,or a
<br /> certified copy thereof('ecti n 3800,Labor Code).
<br /> Expiration Date �,' Company )�LC 2•�
<br /> ❑Certified copy is hereby furnished
<br /> ty'Certified copy Is filed with the Environmenlal Health Department
<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 /> 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'Compensatlon Laws of California.
<br /> Date:_ Applicant
<br /> NOTICE TO APPLICANT:If, after making this Certificate of Exemption,you should become subject to the Workers'Compensatlon
<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 /> O 1 hereby certify that no excavatlon five (5)or more feet in depth Into which a person Is required to descend, will be made In
<br /> connection wlth 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,jdHe-S,,California Administrative
<br /> Code).
<br /> ❑As owner-builder,i will not employ anyone to do work which would require a permit from theD Islon of In\Irial Safety,as rested
<br /> above,unless such person has a permit to do such work from the division.
<br /> 13 Division of Industrial Safety Permit n J
<br /> 1 certify that I have read this application and state that the above InformatiIC'flon,
<br /> t.�aqd
<br /> agree,' comply with all citynd county
<br /> ordinances and statg laws relating to well construdlon and or sewage system here authorize represenyetives of this
<br /> county to enl r upo the a�2ove-mentioned property for Inspection purposes
<br /> �
<br /> Datey Applicant
<br /> r ,
<br /> EHD 43-C7 L 9 CONTRACTOR DECLARATION
<br /> EH 07
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