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JOB ADDRESS:19 .gtiT- 11(d PERMrr #4u Pa d 40 4� 4 J LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code ai id my license Is in full force and effect pcf Expiration Date 7Z License # .7 f —r Date .$ 10 0 ;O Contractor /qN it-` .�OiU3 /A!C• OWNER -BUILDER DECLARATION I hereby affirm that am exempt from the Contractors License Law for the following reason (Section 7031.5, Business and Professions Code: Any city of ounty which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the ar plicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractors License Law (Chap er 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the b sis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I iot more than five hundred dollars ($500)): ❑ I, as owner of tI ie property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offe ed for sale (Section 7044, Business and Professions Code: The contractor's License Law d s not apply that owner of properwho builds or improves thereon, and who does such work himself or through his own employees. provided such improverni nts are not intended or offered for sale. If, however,1 the building or improvement is sold within one year of completion, the wner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ IPaofe Professions Coe (B&PC):aThe Contractors clusively License Lawlicensed does not applycontractors to an owner construct o owneo property who builds orimproves hereo , and who constrt cts for such projects with a contractor(s) licensed pursuant to the Contractors License Law.) O 1 am exempt un r Section B&PC for this reason Date: Owner -WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 38)0, Labor Code). /� Expiration Date �� 2�Z� Company 9,0�z/ le,�rf}� ,//N CI Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need of be completed if the permit Is for one hundred dollars 100 or less I dertify that in the erformance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date,Applicant r NOTICE, To APP ICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisigns of the L ibor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm tha there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code):; Lender's Name Lender's Addres DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby cert' that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection wit I work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will bE more than thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative Code). ❑ As owner-builc er, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. ❑ Division of Indt stria) Safety Permit # i certify that I ha a read this application and state that the above information Is correct I agree to comply with all city and county ordinances ands ate laws relating to well construction and or sewage system construction, and hereby authorize representatives of this county to enter ul on the above-mentioned property for inspection purposes. Date Applicant EHD 43-02-007 I LICENSED CONTRACTORS DECLARATION 6-26-09