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Ptsartr # LICENSED CONTRACTORS DECLARATION 1 hereby alrinrh that I am licensed urAlor the provisions of Chapter 9 (cominexnein9 with Section 7000) of Division 3 Of the Business and Professions Code and my lime is in Rint Rine and effect. t ' License # 1 f) P5 !A 7�5 tri Expiration Date Dale '%-- 2 -.2Q 2� Contractor t V Fir _n, A c, V A I rn 0 OWNER43UR-DER DECLARATION I hereby affirm that 1 am exempt from the Con ra"s License Law for the fpeowing reason (Section 7031_5, Business and Professions Code: Any city or county which requires a permit to construct alter, imp uw, demolish, or repair any shuctim prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (cor merwing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for tho allepod exempti— Any v666. of ,Section 7031.5 by any applicant for a permit atbje= the applicant to a civil PAY of not mire Hymn rive hundred donars ($500)x O 1. as owner of the property, or my employees with wages as their sole compensation. will do the work, and the structure is not untended ar offered for sale (Section 7044, B skwss and Professions Code: The contractor's License taw does not apply to an owner of PrOPertY wino bulls or onproves thereon, and vvbo docs such work htinseM or through his own employee!, provkfed that such rmpruvements alt not intended or offered for sale_ If. however. the building or Improvement 5 sold wither one year of wrnplebpn, the Owner budder Will have the burden of prOn g that he rid not btM or improve for the purpose of sate ) ❑ 1. as owner of the Property, am -cl sively g with licensed contractors to construct the Project (Section 7094. Business and Prrofessions Code (B&PC)_ The C mit actor's License Law does not apply to an owner of property who breads or improves hereon, and who corshucts for such prmjects with a contrarbor(s) licensed pursuant to the Contractors License Law.) O 1 am exempt under Section , BB,PC for this reason Die: WORKERS' COMPENSATION DECLARATION I thereby affirm that I crave a certificate of consent to seif-jnsure or a certificate of Workers Compensation Insurance, or a certified copy thereof (Section 3500, Labor Coder Expiration Date -- Company 13 Certified copy is hereby furnished O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be comdehrd H the merttffi is for Whir htrdred dollars fS1o01 or less) I carttTy that in the performance of the work fpr which this permit is issued, i shall not empty any person in any manner so as to become subject to the Workers Compensation Laws of California- Data: alifornia Date: NOTICE TO APPLICANT: If, atter making this Certificate of Exemption you should become subject to the Workers! Compensation provisions of the Labor Code, you must forthwith comply with such Provisions or this permit shall be deemed revoked_ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a cuFwuchon tending agency for the performance of the Civil Code). work for which this pertnrT is issued (Section 3097. Lender's Narne Lendees Address D[M1ON OF INDUSTRIAL SAFETY PERMIT CERTIFICATION El I hereby tae" Mt no excavatum five (5) or more feet in depth into which a person is reeuaed to descend, wall be made in Connection with work authorized by the permit and that no buad"rhg structure. scaffolding, fasewr or demotion or disroarffmg thereof, will be more than thirty -sic (36) feet high. (Chapter 32- Group 2, Article 2. Sodium 341, Tale 8, California Administrative Code) - [3 AS 011iner4 lalder. 1 welt not employ anyone to do vmrk which would requie a Pemnit from the Division of Industria! &ofcty, as noted above, unless such Person has a Permit to do such work from the division. O Division of Industial Safety Permit # I certify that 1 have read this application and state that the above information is correct_ 1 agree to Comply with a9 city and county admixes and state taws relating to well Ccprstruction and OF sewage system construicfim and hereby authoem represenhtivas of this county to eater upon the above-,nentioned property for inspection purposes. Date aMasa2-0or c -25-w Applicant