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Joe ADM ESS: PERMri N: LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under the provisions of Chapter 9 (coimrnwxkng with Section 7000) of Division 3 of the Buenas and Professbrts Code ane my license is kn pus force and affect. Q License 1 C ~? – —7 { (70`1"'1 Exp1 tion Darta, 3 C r Date Tj . l Contractor tK) 00 ) rt t l OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from M» Contraebr's Liwas Law for the follow" reason (Section 7031 5, Business and Professions Code Any city or county which requires a permit to construct, abler knprove, dilnx" or repair any arucuure, prior b Its Issuance. also requaes the applicant for such permit b fie a slgr»d statement that he Is licensed pursuant lo the Provisions of the ContwWz License Law (Chapter 9 (cornmencinq with Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt herefrom and the basis tor the alleged exilimpbon. Arty vioistion of Section 7031.5 by any appica(r nor a permit subjects the appicant to a civil penalty of nor more than five txmdred dohs (i500)): ❑ I, as owner of the properly or my employees with wages as their sole compensation, will do Ms work. and the xtucwre is not intended or offered nor sale (Section 7044, Business and Professions Code The contactors Licanse Law does not apply lo an owner of property who builds or improves thereon, and who does such work hkrnelf or through his own employ*" provided Meat such knprovements are not intended or offered for sale H, however, the buidhg or improvert»nt is sold wtthln one year of completion, the owner builder will have the burden of proving that he did nor build or knprove for the purpose of 9@40) ❑ I. as owner of the property sm exclusively contracting with licensed contractors lo constrict the project (Section 70" Business and Professions Code (83PC) The Contractors License Law does not apply lo an owner of property who bulkfs or improves hereon. and who constructs for such projects with a contractor(s) licensed pursuant b the Contractors License Law) ❑ 1 am exempt under Section . Bit PC for this reason Date: Owner: WORKERS' COMPENSATION DECLARATION I hereby atfirrm that I have a certificate of consent to self -insure or a certificate of Workets Compensation Insurance, or a1N Explied copy t et1(section, 3800, Labor code) n � Expkstbn Date l �_ Company jam' ('^,' ❑ Certified copy is hereby ftxnished ❑ Ceftrfied copy Is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (_This section heed not be comdeted tl the oermn la for one hundred dollars ($100) of less) I certify that In the performance of the work for which this permit 4 issued, I shah not employ any person in any manner so as to become subject to the Workers' Compensation Laws of CaMomia Date: Applicant _ NOTICE TO APPLICANT H, after making this CertHfcate of Exemption, you should becorrs subject to nth Workers' Corrhpermation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shah be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work far which this permit Is issued (Section 3097, Civil Code). Lenders Name Lender Address DPASION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify than no excavation five (5) or mon feel In depth Into which a person is required lo descend, will be made in connection with work authorized by the penTK and that no b uidWN struckxe, scsdfoidkhg, Weework, or demolition or dwnanuinq thenad, wit be mors than Mhi ny-six (36) feet high. (Chapter 3 2, Group 2, Article 2, Section 341, Title 9, California AdmWstrattve Code) ❑ An owner brrl cW 1 will not empioy anyone to do work which would require a permit from the Divialon of IndustrW Safety as need aboveunless such person has a permit io do such work from the division ❑ Division of Industrial Satiety Permit 0 I Gently that I have reed this application and state that the above information k correct I &pies to comply with all city and county ordinances end state laws relisting to well corstrtxlbn and or sewage system construction and hereby authorize representatives of this county to anter upon the above-mentioned property fo( hspectfon purposes DateAPpllurlt 2 LyG�iCc�YlLIJ� E11D U 07 LICENSED CONTRACTOR DECLARATION .7