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e w / JLB ADDRFSS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(corttmencing with Section 7000)of Division 3 of the Business and Professions Code, and my license is in full fora and effect. Ucense#_ _Exp.:Dam Date__Con4-actor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Conuactor's License Law for the following reason(Sec.7031.5,Business and f'r fessions Code; Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prier to its issuance,also rrgoires the applicant for such permit to file a signed statement that he s licensed pursuant to the provisions of the Contractor's License Lrw(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjcets the applicant to u evil pcnalty of not marc than five hundred dollars ($500)): ❑I,as owner of the property,or my employees with wages as thcir sole compensation,will do the work and the structure is not intended or offered fur sale (Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of prope:ry who builds or improves thescon,and who ` does such wort:himself nr 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 compiletwn,the owner-builder will have the burden of proving that he did not build or improve For the purpose of sale.) V C1 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:The Contractor's Ucensc Law does not apply to an owner of property who builds or improves thereon,aril who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) 17 1 am exempt under Sm. B&P.C.for this reason f k Date Owner 4 WORMS'COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self-insure,or a ceCifrcate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800, i LAh.C). Fxp.Dare___Company --. ❑Cenifmd copy is hereby furnished ❑Certified copy is filed with the County Building rnspccrion Divisioa CERTIFICATE OF FXEMPTTON FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed,if the permit is for ox hundred dollars(S 100)or less) I certify that in the performance of the work for which this pcmtit is issued,I shall not emplo;any person in any manner so as to become subject tot he Workers'Compensation Laws of California. Date Applicant— -- I ?NOTICE TO APPLICANT:If,after making this CertiFicare of Exemption,you should become subject to the Wotkers'Cumpeasatiun provisions of the i Libor 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 wustsuctiun lending agency for the performance of the work for which[his permit is issued(Sec.3097.Civ.Q. ' Lender's Name t.endcr'.s Addr¢ss DiVOWN OF INDUSTRIAL SAFETY PERMIT CERTTFICATION: L2 I hereby certify that iv,excsvation five I5)or mere feet in depth into which a person is required to dcseend,will he makc in conncnion with work authorised by the perrnit.and that no building structure,:caffulding,falsework,or dernolition or disnwntling thereof,will be inure than thirty-six(36)feet high. (Chap.3.2,Grp 2,Art 2,Sec.941.Title 8.C.A.C.)• I ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial.Safety.as eoted above,unless such person s a permit to du such work-from the division. ❑Division of Industrial Permit No. I certify rhat I have read this application and state that the above information it correct.I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage syetem construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspectisn purposes. r' Date_ Appliwn[__^_ �_�—_ i I �: