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FJoBADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 0(commencing with Section 7000)of Division 3 of the Buslness end
<br /> Professions Code and my license Is i full force and effect.
<br /> Licens
<br /> e , r ` 1 Ex rationDat
<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 Contractors
<br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt
<br /> herafrom 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 of 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 Professions 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 bulli 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 /> find who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law,)
<br /> 111 am exempt under Section , B&PC for this reason
<br /> Dato: Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-Insure or a Cale of Workers'Compensation Insurance,or a
<br /> certified copy thereof(,ectl n 3800,Labor Code). r
<br /> Expiration Date (,' Company
<br /> ❑Certified copy is hereby furnished
<br /> gCertifted 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'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'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 /> Lander 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 Biat no building structure,scaffolding,faisework,or demolition or dismantling
<br /> thereof,will be mofe than thirty-six(30)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,'[life-8 California Adminlstrattve
<br /> Code). /
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the D Islon of Indus tial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit Y
<br /> I certify that I have read this application and state that the above Information is correct. I agree. comply with ail city nd county
<br /> ordinances and stat laws relating to well construction and or sewage system conslrycilon,arid here authorizerepresen tives of this
<br /> county to ent r upo the move-mentioned property for Inspection purposes. J n
<br /> Date Applicant
<br /> EHDA&C7 9 CONTRACTOR DECLARATION
<br /> 10;5107
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