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<br /> JouADURk". 20 1- ►dam �a� - p�0
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1114roby air-:n Nat I am lizansw undo'va prnw;ions of Chayer 9(commoner,41t�j secvon 7(mj f 17Nissa^3 of ha 7�s rasa and
<br /> Profesabns Cade and m A onsw i.in"fo-ce a%c erect
<br /> Uceinse N j_ Expiration Data
<br /> Date Contractor b jptl!�'�i`+ 1�z
<br /> OWNER-BUILDER DECLARATION
<br /> I nareyy affirm that I am ennim holt t-te Cant- "Ieti Lk:err.e;^I;r 1-,e(chewing reason,'SeCuon 7031.5,Business and Profegsfprs
<br /> Codi My City or:D rely'wilon.requires,a peri b In nnnr ruN,alter,improva demodsr,or vux any stn,dura,prior a Its Issuance-
<br /> also
<br /> ssuancealso reo:ores the appscant for such"trot to ft a rived statement that-+e 4 licensed pursuant to the provisions of the ConWctoes
<br /> Licenia Law(Chapter 9(rnmrnortuiry wm Secton 7000)o'Dvls:or,3 of the Business anis F'rolermcn9 Coes;,or That he Is Oxentpl
<br /> herstrom and the coatis our fire nNnow,esemoon_ Any vlolal N"Se:ton 7u31 s Gy arty applicant for a peRr t subjeeU lho appwanl
<br /> lu a Ovil uenary of nol mnrr than five hurdrea dowers(5506))
<br /> O �.as owrw of Lha property,tr-my employees w th wnpgs as their We Corr Wl8t;'t will Cc the WCC.rants tho struct wd Is nOt
<br /> intended or vfterad for BALs(Sirrlinn 70".RV91neris end Rrotesaldcs Code. The 6ortlractur s t ioanse.aA toes nzt aWy to an
<br /> ownrr of property woo Diads or imvvoos thereto.and whin of.§,wort himself or through h:s OW1 111:1p)oyeec,provaed that
<br /> such !mprovements are Rot inlenow or a-twoo to sale J. hnwevv. Che building or inp^:Vansnt a sole w+thm one freer of
<br /> comWetlon.the owner-builder w II have the burden cl rxoving it*he did not b,,Iid of Irr;,*Cvo'x the purpnu of;ale)
<br /> ❑1 ae ui rs at Nov.property,am excluslv'e:y,Co-facttrq with:�zense.Ccrtrauuis to r cnclr.irl thin Pmject,'Secilcn?Q44,IA,sineac and
<br /> proli Code(WC)! The Ccr:rettars:iunse taw deer not appy w an owner of p,Darty vrho builds or enpreveu hereon, ,
<br /> and who constricts for sum projects vdtr a Cdntractols)'r06rmmr pu+suaal to the Conlbv toes Lice-so'aw.;
<br /> D I an exan-A Ards.-Sacs or, gSa. Inr this reason
<br /> Date: Owner:
<br /> WORKERS'CCMPENSATiON DECLARATION
<br /> I hereby effi m that 1 have s car iflate of consent to errlr•Insure or a otartiFcate of Workers'Compensation Inswanco.ore
<br /> r:nrtinarl r:cttty llfe(oof{Suction 38DO,Lebow Code). nn� aa
<br /> Expiration Data_0f-D�"�)S Company::I_ ilk!,
<br /> OCeriified copy Is hereby furnished
<br /> pt Cenitied cony is creed with the Environrnentsl Ibalm Deparbnent
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> Th!s SeCber need not baa Comolatad rf ttgIvMa er rot vete handfed dotlars fS100±or leas
<br /> eartif)that in the pednrouirw of the work for which this permlt Is!tsued,I Shia:not employ any person in any manner so
<br /> a3-c cecome&Acct 10 the Workers'Compensalion L:,ws of California.
<br /> Dole- Applicant_..
<br /> hOT{CE TO APPLVCAYT:0.&fW making Urns Undi?imin or F-envidon,yo.t sticvAd become suhjar. ;o the Arcrkr�'Conpensallon
<br /> pnrv,srons of Int.Labor Code,you rr.W for *iM Corri*Wh s,.ch provis4?na or mrE perp>l shall br rsemed"evoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> i I hsrtrby affirn akst L'rvre is a cvnstr_chv,lend'nq agarcy b"tie pe'formanoe of the worn for wraith Lnls perm,Is Issuac.
<br /> (Section 3097.Civil Code) i
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> O 1 hereby cerdty Ma;no exravabon 7ve (5)nr ro"e feet t:devlh tiftD wheh a person is required to e.. "d w4i be made In
<br /> covacuon w!h wvn,+Ahnrized by eta parr-it and that ro building structure,scetfotdiny,tjlh.worx.or demolition or discos%Ikny ,
<br /> Ilwn'rit,visa tit!mor:frian e'e-l"ift(W fee!hlpt.(Chapter 3.2 Group 2 P.nrcia 7,Rtwtc,34'.Tide 0,Caldor'ua Aomm,itratve
<br /> C(44 11
<br /> 0 As ownsr•bulider,!wit-tit employ anyone to do work%hid-would require a Peril from ft Lvlsion a'tnd-40101 cs noted
<br /> above,unless such parson has a neurit to On sudh work hem t"dlvalon
<br /> O Divta,ry a-fr.durdr Safety Parrott a
<br /> I crrfi'y inn- I have read tnls application ars stale that the above intonT,aboa is correct I aprar in campty wth alt GS(a."§d county
<br /> ordinances and Kele iavn rest,to WON Construc4iw aid or wrwaye syehen const tion,and hereby eu Orin press vas Ot this
<br /> k county 10 enter u0o1 t•^,e above-menu'or/led property for rispod on purposns.
<br /> Data rlY" Applicant
<br /> I
<br /> :w:•v<+ t.CENel6 COsrtaacrOa or�tiuraric�s
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