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JOB ADDr Ew: 23-2:2 / &. _ Peau LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under the provisions of Chapter 9 (Conrtnencinq with Section 7000) of Division 3 of the Business and Professions Code and my license is m full lfforce and effect. Litxrtse $ 1 t S '� L ✓� F�hation Date. '- �D — 2—o2j Dam 7-1 !- Zo z} contractor N Pr r, A',-) V t n OWNER-t3U0.DER DECLARATION 1 hereby affirm that I am exempt from the Contracts License Law for the k4awing reason (Section 7031.5. Business and Professions Coo- Any city o county which requires a pemA to construct, aper, improve, derndish, of repair any strucbye, Prior to its ice, req'>m3s the apppgrt for Such permit to Ute a sgned staWn"It that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (cormnencng with Section 7000) Of Din 3 of the Baaenesa and professions Code) or that the is exempt aatrorm and the basis for the alleged examPti Any VMietian of Section 70315 by any ap m t for a perarfrjocta the appsm t to ta civil penalty of rot more titan five hundred dollars (SSoo ))_ O I, as owner of the property, or my employees with wages as their sole compensation. will rho the work. and the stnidu a is rot intended or offered for sale (Suction 7044, Business. and Professions Code. The contractors License Law does not apply to an owner of ProPe+ty who builds OF imProties thereon, and who does such work hknself or through his own employees. provided that such I+"Ptovemtt erare not untended or offered for sale if however, the baulafrng or unprovernent s sold within one year of corraP"M, the owner-bUadel wil have the bwden 0f prov09 that he did not bold or improve for the purpose of sale-) 0 1. as owner of the property, am exci lively mr6actirng with kcensed contractors to c the project (Section 7044, Business and Professions Code (B&PC)- The Contractors license Law does not apply to an owner of property who bukisor improves tneveom and Who constructs for such Projects with a contractors) pursuant to the Contractors License Law_} 13 1 am exempt under Section , B&PC for this reason WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self4mure or a certificate of Workers' Compensation Irmirance, or a certified copy thereof (Section 3800, Labor Code)- Ezpirafion Date Comoanv 0 Certified Copy is hereby furnished 13 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION WSURANCE fThis sermon reed not be 00mg*rted if the oe_ .it is for one trundred dollars fS7 r)Ol o less) 1 certify that m the performance of the work for which this Penin is issued. I shall not employ ant' person in any become subject to the Workers' Compensation Laws of California.marcher so as to Date' ApplicaM NOTICE TO APPLICANT_ ff. after rnaldng this Certificate of Exemption, you should become subject to the Workers' Compilation provis+orLs of the Labor Code, you must forthwith comply with sunt pfovisiot5 Or this Permit shad the deemed revoked - CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction lending agency for the performance of the work for which this permit 's issued (Section 3097, Civil Code)_ Lender's Nam Lender's Address DLW51ON OF INDUSTRIAL SAFETY PERMIT GERTIFIGATION 1 hereby cefUry that no excavakiri five (5) or more feet in depth into which a person Ls required to descend, well be a_d.:. thereof, w0 be more thane by she pgrnit and that no bolding structure, scaffolding. f2lse-"k or demoWon ar dismanr6ng CMnQCt[dn with work Code). (W) feet high_ (Chapter 3Z Group 2, Article 2, Section 341. Title 8, Catgor, Administrative As owner -buckler. I wia not employ anyvrre to do work which would require a permit from the Diveion of Industrial Safety. as rioted atrove, unless such Person has a permit to do such work from the ttivhsiort_ 13 Division of Industrmw Safely Permit # I Certify that I have read this application and state that the above information is carteCL I agree to comply with an city and county ordinances an state kms relating to well construction and or sevvatde syr cone, and hereby autttor¢e representatives of upon Ltrc; pthe abve rmodened Property for em pection purposes Date 52rrm Applicant