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R S a JGIB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION 1 hereby affrri that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busimm,and Professions Code, and my license is in full force and effect. License fi m Exp.-.Date Date Contractor OWNER-13UILDER DECLARATION I hereby affirm that I am exempt from the Comractor's License Law for the following reason(Sec.70315,Business and Professions Code-, Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for suet permit to file a signed statement that he ii licensed pursuant to the provisions of the Contractor's License law(Charter 9(commzncing with Section 7000)of Division 3 of the Business and Prok:uions Code)or that he is exempt hcrefrom and the basis for the alleged exemption. Any violation of Section 7[131.5 by any applicant for a permit subjects the..applicant to a civil penalty of not more than five hundred dollars ($900)): Q 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec.7044,Business and Frofcssions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon.and who does such work himself or through his own employees.provided that such improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of compie<ion,the owner-builder will have the burden of proving that he did not bui id or improve for the purpose of sale.) 111,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:The Conttuctor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractnr(s) licensed pursuant to the Contractor's License Law.) ❑I am exempt under Sec. 3$P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-inure or a eert;ficate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800. Lab.Q. Exp.Date Company _ Q Certified copy is hereby furnished ❑Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed,if the permit is for one hundred dollars($100)or less) - I ccrti fy that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Date Applicant NOTICE TO APPLICANT:If,after making this Csrti ficatc of Exemption.you should become subjeLl to the Workers'Compensation provisions of the Labor Coda you must forthwith comply with such provisions or this permit shall be deemcd revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction leading agency for the performance of the work for which this permit is issued(Sec,3097.Civ.Q. Lender's Namc Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑1 hereby certify that no exca:vadon five(5)or more feet in depth into which a person is required to descend,will be make in connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or disman[fing thereof,will be mere than thirty-six(36)feet high. (Chap.3.2,Grp 2,Art 2,Sec 341.Title$,C.A.C). 13 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as no<ed above,unless such person has it permit to do such work from the division. ❑Division of Industrial Permit No. I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to Weil construction and or sewage system construction,and hereby authorize representatives of this county tc,r tic above-ntertioncd property for inspection purposes. Di tc_ Applicant i ,