|
JOB ADDRESS'..'-I V l t />-oC6 (�r( PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> hereby affirm that I am licensed under the provisions of Chapter B(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and m_y license Is full force and effect.ContLicense# �
<br /> t— �� Ex ration Dat
<br /> actor ,�
<br /> Date
<br /> OWNER-BUILDER DECLARATION
<br /> 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 Contractors
<br /> License Law(Chapter 0(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 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 Prefesslons 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-builder will have the burden of proving that he did not build or Improve for the purpose of sale,)
<br /> d I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business arxl
<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-instrre,or a tale of Workers'Compensation Insurance,or a
<br /> certified copy thereof( ectl n 3800_,Labor Code). 7 r
<br /> Expiration Date U' Company
<br /> 13 Certified copy is hereby furnished v
<br /> l Certified copy Is filed with the Environmental 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'Compensation Laws of California.
<br /> Data: Applicant
<br /> NOTICE TO APPLICANT:If, after malting 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 /> ❑ 1 hereby certify that no excavation five (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,falsework,or demolition or dismantling
<br /> thereof,will he more than thirty-six(3a)fent high.(Chapter 3.2,Group 2,Article 2,Section 341,)Ae�A Calirarnia Administrative
<br /> Code). \
<br /> ❑As owner-builder,1 will not employ anyone to do work which would require a permit from the D Islon of Indusldai Safety,as noted
<br /> above,unless such person has a permit to do such work from the division. i.
<br /> ❑Division of Industrial Safety Permit K
<br /> , r
<br /> certify that I have read this appllration and state that the above informallon is correct. I agree, comply with all citynd county
<br /> ordinances and stat laws relating to well construction and or sewage system consh ctlon,a9d here authorize represenfiWies of this
<br /> countyto ent r upo thea ve-rnentioned property for inspection purposes. I 1 n
<br /> Dale ) r
<br /> l
<br /> Applicant t±� ! , y /�Z��,•�
<br /> EHD 4307
<br /> 10;5lO1 tic 5 CONTRACTOR DECLARATION
<br />
|