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JOB ADDREss: Z1 ZJ1 ; t!) if) /2(4 • mcf PE:Raiff& UCENSED CONTRACTORS DECLARATION hereby affirm that I arn Ncensed under the provisions of Chapter (commencing with Section 7000)of 017 3 e(age Bigistx:13 — Professions Code and my license is in full force and effect_ License # 2 1-klr;-) Expiration Date iitE0=4201.2--1-- Date (J, — 7 0 "Z. I Contractor N) Pc c\ OWNER-BUILDER EIECLARAllON I hereby affirm that I am exempt from the Contractor's license Law for the following reason (Section 7031.5, Business arid Professions Code: AnY city or county which requires a permit to construct, alter, improve, derrOish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a sinned 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 herefrorn and the basis for the alleged exemption_ Any violation of Section 7031.5 by any ap,uit for a wane subjects the appricant to a civil penalty of not more than five hundred dollars ($000)) o ; I. 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 (Section 7044, Business and Professions Code: The contractor's license Law does not apply to an owner of property who builds or improves thereon, and who doos 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 completion, the owner-builder will have the burden Of proving that he did not build or improve for the purpose of sate.) r. as owner of the property, am exciusVely contracting with licensed contractors to construct the project (Section 7044. Business and Professions Code (B&PC): The Contractor's License Law does not apply to an owner at property who builds or improves hereon, and who constructs for such projects weft a contractor(s) licensed pursuant to the Contractor's License Law.) I am exempt under Section B&PC for this reason Dale: Owner WORKERS' COMPENSATION DECLARATION hereby affirm theft have a certificate of consent to sell-insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Labor Code). Expiration Date Company Certified copy is hereby furnished O Certified copy is filed with the Environmental Hearth Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE CMS section need not be completed if the permit is for one hundred dollars ($100) or less) 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 as to become subject to the Workers' Compensation Laws of California_ Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION I hereby certify Mat DO excavation five (5) Of more feet in depth into which a person is required to descend, will be trade in connection with work aultionzed by the permit. and that no building structure, scaffolding, falsework, or demolifion or dismantling thereof, will be more than thirty-six (36) feet high_ (Chapter 3.2. Group 2, Article 2, Section 341, Tttle 8, California Administrative Code). 13 As owner-budder, I will not employ anyone to do work which would roquire a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. 13 Division of Industrial Safety Permit # certify that I have read this application anti state that the above mfonnabon is comet_ I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system consbudion, and hereby authorize representatives of this mu* to enter upon the above-mentioned property for inspection purposes_ Date Applicant Ell) 43-02-007 5-26-09 L/CDISEO CONTNICTORSOECutaKnoir