|
r- --
<br /> JOB ADDRESS: `�S 0 y C—A M AA)C N C L..45r N E
<br /> PERNfr#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is in full force and effect.
<br /> License#
<br /> 5147737 Expiration Date 1 3 0 Z O L Z
<br /> Date �G /1 7 / 2.0 2-I Contractor 7-21 CO tJ n1 T-}'
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Any city or county wNch requires a permit to construct,after,improve,demolish,or repair any structure,prior to its'issuance,
<br /> also requires the applicant for such permit to fie a signed statement that he Is licensed pursuant to the provisions of the Contractors
<br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefrom end the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than Ave hundred dollars($600)):
<br /> O I,as owner of the property,or my employees with wages as their sob compensation, will do the work,and the structure Is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an
<br /> owner of property who builds or Improves thereon,and who does such work himself or through his own employees,provided that
<br /> such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractor's License Low does not appy to an owner of property who builds or Improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section B&PC for this reason
<br /> Date: Owner - --- - -
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certiricate ofconsent to self-Insure or a certificate of Workers'Compensation Insurance,or a certified copy
<br /> thereof(Section 3800,Labor Code).
<br /> Ex hnstin Date Z 3 I 20 Z 1 Company 51 °� Fy^J-0 CO m ACAIS,4?n(/W /i✓S1 r rL iF^/ct
<br /> iCertifeo copy Is hereby furnished
<br /> ❑Cart6ed copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section reed not be comofeted if the permit is for one hundred dollars($100)or less,
<br /> I certify that In the performance of the work for which this permit is issued,I shall not employ any person in any mariner so as to
<br /> become subject to the Workers'Compensa8on Laws of California.
<br /> Date. Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued(Section 3097,
<br /> Civil Code), �/�
<br /> Lender's Name
<br /> Landers Address
<br /> J DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> I hereby certify that no excavation five (5)or more feet In depth Into which a person is required to descend,YAM be made In
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 32,Group 2,Article 2,Section 341,Title 8,California Administrative
<br /> Code).
<br /> ❑As owner-builder,I will riot employ anyone to do work which would require a permit from the Division of Industrial Safely,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit# _
<br /> 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
<br /> ordinances and state laws relating to wall construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon above-mentioned property for inspection purposes.
<br /> Date 1 20 Zf Applicant 7Y7,1 CO tJ h%T-e 1) jej Ltd (r.
<br /> END 13-02-007 LICENSED CONTRACTORS DECLARATION
<br /> 6-2"9
<br />
|