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JOB ADDRESS: 3 U Y /V-4 J V a,,,( .� PERurT#:
<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 end my license is in full force and effect.
<br /> License# 54 7 7 37 Expiration Date l 3 0 Z 0 2:Z
<br /> Date !7 Zit 2 I Contractor T/Z l CU u 7.1 T'}' D 2 L�.l rJ tr /t1 c.
<br /> i
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,
<br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provislons of the Contractor's
<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 and 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 five hundred dollars($500)):
<br /> ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not
<br /> Intended or offered for sale(Section 7044,Business and Professions Code:The contractors License law does not apply to an
<br /> owner of property who builds or Improves thereon,and who does such work himseff 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.) I
<br /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and I
<br /> Professions Code(BPC): The Contractors License Law does not apply 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 Contractors License Law.)
<br /> ❑I am exempt under Section BSPC for this reason
<br /> Date: Owner — -
<br /> WORKERS'COMPENSATION DECLARATION
<br /> II hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy
<br /> thereof(Section 3800,Labor Code).
<br /> E/xpiration Date Z 3/ 2 Z! Company S?�r-fi Fy�D GO »9 PCn/S,�Tt 010 /n/Sf'rt^-rCC
<br /> 0 Certified copy is hereby fumished
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed 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 penton In any manner so as to
<br /> become subject to the Workers'Compensation 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 IJ
<br /> A
<br /> Lender's Address
<br /> 0/ 1
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> 0 I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling i
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative i
<br /> Code)_
<br /> ❑ As owner-builder.I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,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 well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to ern�ter upon tie above-mentioned property for inspection purposes.
<br /> Date l01f7 /+ZDZf _ �'-at C,OJNT-e p �.)"tJ(r. f
<br /> Applicant
<br /> EHD 4302-007
<br /> 8.2609 LICENSED CONTRACTORS DECLARATION
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