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• JOB ADDizr-ss__ i / Yi 1U /! �'/ PERKr#.- LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chapter 9(eomrhe1111ing wdh Section 7000)of Divrsfarh 3 of the Budness and Professions Code F:--- license s in full(force and effec.4. r� License# 1 Expiration ^ C/ Date - Z- � Coy baetor 1'_ OWNER-BUILDER DECLARATION 1 hereby affinn that t am exempt from the Gonhadors License Law for the following reason(Sec4on 7037.5,Business and Professions Code_ Arty dry or county which requires a pennit to construct,atter,"Prove,demolish,or repair any structure,prior to iLs issuance, also requires the app6cani tier sucm permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the bass for the alleged exemption- Any violation of Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)): 0 1.as owner of the property,or my employees with wages as their sote compensation,will do the work,and the sfnucture is not intended or offered for sale(Section 7044,Business and Professions Code:The contractors license Law does not apply to an Owner of property who builds or improves thereon.and who does such work himself or through his awn employees,provided that such improvements are not intended or offered for sale If. however, the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale-) 13 I,as owner of the property,am exclusively contracting with licensed contractors to construct tate project(Section 7044,Business and Professions Code(B&PC): The ConhactDrs License-I aw does not apply to an owner of property who builds or mgxnves hereon, and who constricts for such projects with a contractor(s)licensed pursuant to the Contractors license Law-) 0'am exempt under Section , B&PC for this reason Date- Owner ---- - -- --..._ WORKERS'COMPENSATION DECLARATION I hereby aftinn that 1 have a certificate of consent to self-insure Ora certificate of Workers'Compensation Insurance,ora certified copy thereof(Section 3800,tabor Code)- Expiration Date Company_ _ ❑Certified copy is hereby furnished - 0 Certified copy is filed with fume Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (this section reed not be completed if the permit is for one hundred t loflacs(�100 cr lq� I certify that in the perfotmanoe of the work for which this permit is issued,1 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_It,after making this Certificate of Even — provisions of the Labor Exemption, s should become subject to the eked. s'Compensation Code.You must forthwith comply with such provisions or this permit siratl be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that thefe is a construction lcaxfing agency for the performance of the wort for which this permit is issued(Section 3097, Civil Code)- Lender's Name Lender's Addrrss DIVISION OF INDUSTRIAL SAFETY pERm T CERTIFICATION 17 1 thereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with Wolk authorized by the permit,and that no buMoN strtxwre,SM901(fing,Wbework,or defflofit m or QWWthng thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,C,mup 2,tVucle Z,Sefton 341,Tole 8,Caif7ornia Administrative Code). 0 As owner-builder,I will not cznploy anyone to do work which would require a permit from the Division of Indu sstreul Safety,as noted above,unk�:mh person has a permit to do recur work from the drvisko 0 Division of Industrial Safety Permit# I certify that I 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 well Construction and Or sewage syster construction.and hereby authorize representatives of fns county to enter upon the above-mentiO property for inspection purposes. Date - Applicant END 43-02-00! UICENSED CONTRACTORS DECLARATION fr26-W