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JOB ADDRESS: �41&19 "' 1f11,1fX,T PERMIT #:� 06
<br />!I
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm thi it I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
<br />Professions Codi and my license is In full force and effect.
<br />License# S T`f Expiration Date
<br />Date 3 �- �o x0 Contractor�If-`1 �pif1J /NG
<br />OWNER -BUILDER DECLARATION
<br />i hereby affirm th 3t I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions
<br />Code: Any city i ir 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 provisions of the Contractor's
<br />ision 3 of the
<br />usiness and
<br />hee from andnse Law (thbass forththe exemption. Any violation commencinwith Section 7000) of lvof Section 0316.5 by any applicant for a permitrofessions ) or that he l subjects theapplicant
<br />to a civil penalty of not more than five hundred dollars ($500)):
<br />❑ 1, as owner cf the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br />intended or cffered 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 Improv ments are not intended or offered for sale. If, however, the building or improvement Is sold within one year of
<br />completion, ti is owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br />❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br />Professions ode (B&PC): The Contractor's License Law does not apply to an owner of property who builds or Improves hereon,
<br />and who constructs for such projects with a contractors) licensed pursuant to the Contractor's License Law.)
<br />❑ 1 am exempt t rider Section B&PC for this reason
<br />Date: Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm t at 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). nn
<br />Expiration Da e��� 2 020 Company 6441Ir
<br />v`�D iT�L �� sV21fN
<br />10 Certified co is hereby furnished ���/Cy
<br />❑ Certified cop is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />his section ne d not be completed If the germit is for one hundred dollars ($1001 or les
<br />I certify that in tt ie performance 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 />provisions of thLabor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm vai 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 Nam
<br />Lender's Addr ss
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />❑ 1 hereby c lify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in
<br />connection, Adth work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling
<br />thereof, wifl be more than thirty-six (36) feet high. (Chapter 3,2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br />Code).,
<br />❑ As, owner -b iider, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted
<br />above, unf s such person has a permit to do such work from the division.
<br />❑ Division of Ii idustrial Safety Permit #
<br />i certify that 1 ieve read this application and state that the above information is correct. I agree to comply with all city and county
<br />ordinances an state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this
<br />county toenter upon the above-mentioned property for Inspection purposes.
<br />Date _ _ Applicant
<br />EHD 43-02-007
<br />6 26-09
<br />LICENSED CONTRACTORS DECLARATION
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