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JOB ADDRESS: PEIIM11'
<br />LICENSED CONTRACTORS DECLARATION
<br />1 hereby ai➢lrm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
<br />and my license is in full force and effect.
<br />License N__A Exp.:Date
<br />Date_ __ ___Contractor_
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or
<br />county which requires a pertrtit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such peratil
<br />to file a signed statement that he is licensed pursuant to dee provislons of the Contractor's license law (Chapter 9 (commencing with Sectlan 7060) of
<br />Division 3 of the Business and Professions Code) or that he is exempt Itetnfrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br />any applicant for a permit subjects rhe applicant to a civil penalty of not more than five hundred dollars ($500)):
<br />❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale
<br />(Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who
<br />docs such work himself or through his own empinyccs, provided that such Improvements are not intended or offered for sale. If, however, the building or
<br />improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of
<br />sale.)
<br />0 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Profession Code: Tlie
<br />Contractor's License lAw does not apply to an owner of property who builds or Improves thereon, and who contracts for such projects with A contractor(s)
<br />licensed pursuant to the Contractor's License Law.)
<br />O 1 otn exempt under Sec. B & P.C. for this reason
<br />Date _ Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have it certificate of consent to Self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy Ihereof (See. 3800,
<br />Lab. Q.
<br />Exp, Date _ Company_,
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is tiled with die County Building inspection Division
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSA'T'ION INSURANCE
<br />(This section need not be completed, if the permit is for one hundred dollars ($100) or fess)
<br />I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject tot he
<br />Workers' Compensation Laws of California.
<br />Date Applicant__,___
<br />NOTICE TO APPLICANT: If, after making dos Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the
<br />Labor Code. you must forthwith comply with such provisions or iltis 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 (Sec. 3097, Civ. Q.
<br />Lender's Name
<br />Lender's Addrass
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br />Q I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be make in connection with work
<br />authorized by the permit, and that no building structure, scaffolding, falsework, oto demolition or dismantling thereof, will be more than thirty-six (36) feet
<br />high. (Chap. 3.2, Grp 2, Art 2,.34e 341, Title 8, C.A.C.),
<br />❑ As owner -builder, I will not employ anyone to do work which would require it permit from lite Division of Industrial Safety, as noted above, unless such
<br />person has a permit to do such work front the division -
<br />11 Division of Industrial Permit Nn.
<br />I certify that I leave read this application and state that the above Information is confect. I agree to comply with all city and county ordinances and state, laws
<br />relating to well construction And or sewage system construction, and hereby authorize representatives of this city to enter upon the above-niantioned property
<br />for inspection purposes.
<br />Dale
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