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JOB ADDREi 5: �r �/¢�/¢N% Rd PERMIT#:61)aaa����
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<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 aid my license is in full force and effect.
<br />74Expiration Date
<br />License # .x f
<br />Date 3 3 0 O �O Contractor/rte .2�NJ ANG'
<br />OWNER -BUILDER DECLARATION
<br />I hereby affI7 that am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions
<br />Code: Any city or ounty which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance,
<br />also requires the al plicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's
<br />License Law (Cha er 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
<br />herefrom an the b isis 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 of more than five hundred dollars ($500)):
<br />(7 I, as owner of ' e property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br />intended) or off ed for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an
<br />owner of prope who builds or improves thereon, and who does such work himself or through his own employees, provided that
<br />such improvem nts are not intended or offered for sale. If,, however,1 the building or improvement is sold within one year of
<br />completion, the wner-builder will have the burden of proving that he did not build or Improve for the purpose of sale.)
<br />Q I, as owner of th i property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br />Professions Coe (B&PC): The Contractors License Law does not apply to an owner of property who builds or improves hereon,
<br />and who constn cts for such projects with a contractor(s) licensed pursuant to the Contractors License Law.)
<br />O I am exempt un er Section B&PC for this reason
<br />Date: Owner
<br />Y WORKERS' COMPENSATION DECLARATION
<br />I 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 38)0, Labor Code). 7,
<br />' LISP •rf}G /0V Sock vette _
<br />Expiration Date 7 3i 2020 %� Company <
<br />El Certified (copy is hereby furnished
<br />❑ Certified !copy is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />I certify that in theperformance of the work for which this permit is issued, I shall not employ any person 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 />proyisions of the L itior Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />1 hereby dffirm tha there is a construction lending agency for the performance of the work for which this permit Is issued (Section 3097,
<br />Civil Codef' ,
<br />Lender's Name
<br />Lender's Addres
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />I hereby cer' that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In
<br />connection wit work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling
<br />thereof will b more than thirty six, (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br />Code). f
<br />❑ As owner -bulk er, 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)I of Indi sfial Safety Permit #
<br />I certify that I haa read this application and state that the above information is correct. 1 agree to comply with all city and county
<br />ordinances ands to laws relating to well construction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter u on the above-mentloned property for inspection purposes.
<br />Date Applicant
<br />LICENSED CONTRACTORS DECLARATION
<br />EHD 43-02-007
<br />6-26-09 i
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