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J013ADDRESS 41416-s N�I��I�T �Q _ PERMIT#:1VPo,0 44,0
<br /> 9S�zo
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm tiat 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professi ns Co,ie and my license is in full force and effect.
<br /> License# S 74 E1.Z Expiration Date 7L31V
<br /> /
<br /> Date 1 azo �O Contractor AA11 G�pf-`7 .20N J /love. —�
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm I iat 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 which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,
<br /> also requires th)applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors
<br /> License ILaw(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefroro and&a basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penal of not more than five hundred dollars($500)):
<br /> ❑ I,as owner f the property,or my employees with wages as their sole compensation,will do the work,and the structure Is not
<br /> intended or ffered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an
<br /> owner of pr perry 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 /> comiletton,1 ie owner-builder will have the burden of proving that he did not build or Improve for the purpose of sale.)
<br /> 1,as gwner o 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 w no co tructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 amgxempt rider Section B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> [hereby ffirm tl iat 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). / n
<br /> Expiration D e 7 31 2.020 Company 2A-(/ 1r.4L /0V s! e,+,✓itZ Cp
<br /> ❑Certified cop is hereby furnished1{
<br /> P�u4y y� `TyGG;Zo..o�
<br /> [3-Certifi ad oop is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> his section ne d riot be completed if the permit is for one hundred dollars 100 or less
<br /> 1 certify that in 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 A PLiCANT: if,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> pr6,A6io s of theLabor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> • r.
<br /> i CONSTRUCTION LENDING AGENCY
<br /> I hereby pffirm.ti at there is a construction lending agency for the performance of the work for which this permit is Issued(Section 3097,
<br /> Civil C0041
<br /> Lender's Name
<br /> Lender's Addre ss
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby ce ify that no excavation five(5)or more foot in depth Into which a person is required to descend,will be made in
<br /> connctlon Uth work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling
<br /> thereof-will lie more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8, California Administrative
<br /> Coder.
<br /> ❑ As owner-b ul Ider,141 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 Incustrial Safety Permit#
<br /> I certify.that I h ve read this application and state that the above information is correct. I agree to comply with all city and county
<br /> ordinances and Rate laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county t enter L pon the above-mentioned property for Inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02 007 LICENSED CONTRACTORS DECLARATION
<br /> 6-26.09
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