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Joe ADDREss: _ PE IMIT rt:
<br />LICENSED CONTRACTORS DECLARATION
<br />I heraty utrinn that I am licensed under the provkvi ns of ch,,pi , t+ (l,minionong will, Suellen 7000) of DMsio.r 3 rpt the Bufliness anrl
<br />Prohmsion; Code and my licenrYe Is in lull lorre nmJ ofte.-o
<br />Ucense ft Expiration Date
<br />Date Contractor
<br />OWNER -BUILDER DECLARATION
<br />i hereby afhirn lhoi I am exornpi from the Gontract3ra License Lav, inn tier billowing n+ason (Section 7031.5. Business and Professions
<br />Code- Any city of county which requires a permit to ctnsinAel alrel, in-ivtrrv(i, demolish, of repah any structure, prwr to its issvam-4',
<br />also requires the tiMA ant for such permit to rde a signed staternrrnt flint trit h i vowd pursuant to the provisions of the Cantractor's
<br />LAWnse Low iChapter 9 3comrnencng with Section 70001 of Din"Inr 3 rill the BLtillness and Professions Code: or thw hes exempt
<br />heirelrbm and file basis for the alleged exemption Any viiolalwn of .ectlou 7031.5 by any applicant for a permit subjects the applicant
<br />to a dvlf penalty of no) more than five hundred di -Alan ($5013))'
<br />O 1, as owner of the property, or my enipioymer with wages as them sole compensation, will do the wort(, and the sinx:lure is rail
<br />intended or offered for We (8ftitor+ 7044, Bt.smess and Prtk sanria (.ode The conlrwloi's Lkense Law does not apply to an
<br />owner of property who builds or improves thr}raon, and who doer; tuwls work hire* Alf or thraugih his own empkayees, provided {hal
<br />such improvements are not intended or offenad for sale if, hnwovor, tiro bLakfimg or improvement is sold within one year --A
<br />erxriplefion, the ow"t-builder wr01 have the burden of proving trial lro did ml build or improve for the purpose of rata I
<br />13 I, as cwnef rut the property, am exclusively corhacting with to uirwtruct tete project (Section 70". Buainem. eral
<br />Pnpfecsirm Code (B&PC). The Contractors I conso t aw cloak nut apply to an owner of property who build oe improved ho,non
<br />and who constructa for such pro)ec:ts with n r.nniradrif(s) Ivxoaml pursuant to the Contractors, l.Ir•.ense law 1
<br />1 am exempt under Section _ , l.,Ap ; Jul ihlc• mase,
<br />Date: Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that i itave a cortificale of consent is ;ell-irssula ur a C,tiny ol, rel Workers' Gompenastion insurance, or ,a rerlified a,py
<br />thereof (Section 3000. Labor Credo)
<br />Expiration Rate Company
<br />0 Gerltfi copy is hereby Wrrxstimi
<br />Certified copy is flied with lho Erivirorrmontal F-'e.iltii Departrmoi.I
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATiON INSURANCE
<br />bIBls r>ea wi need not t* camuietug it the oar (�; for ons hunrllr-i duller, 15Ia n! -j"
<br />I certify that in the petinrmnnct, of tho rvaii, for which this permit is Iwatud. ! ! loll nrl imspboy any persop m any rnanne( ev :t•r to
<br />become subject to the Workers' Compensation Ls%s of Calilornis
<br />Date: — Applicant
<br />NOTICE TO APPLtCI$NT. It after malung this G: njticale of Lxrmq lioii, you *Iiould become Fut lect to fhe Worker_' GoInponsatacn
<br />provlgiorts of the Lsabor Code, you must tnrthwith rnmpiv with Gudi piovisrons or this permit shall tw ,1r rflerj rovoucw
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that thorn is a coristruLtion lending agency for trill I -,00o,110 ..4 of lits work Out which this permil Is 13.9uea i i"Ciltin 3097,
<br />Civil Coda)
<br />Litnder's—
<br />Lander's AtfA i — -- -- _-- -
<br />DIVISION OF INDUSTRIAL SAFETY PLRMIT CERTIFICATION
<br />6A, certify trial no excavallaii five (5) e, more feet in depth int,' whir_h a porson is required to dtsscond, will be made in
<br />C with work authorized try tho permit, and that no bruitdinq vinjouro, scaffolding, falsoework, oe ciao oalwn or dismantbng
<br />I10! .VMWI be more than thirty-six (36) feet hIpfi (Chapter 3.,, [mull 2, Atilots 4, Section 3.11, Tittle $, California Administrative
<br />O As owner-butidw, 1 WWI not employ anyone to do work whidt *OukJ require a pem* from fhb Dlvfiiikli of lnduetftl Sa4etv, qts, no*d
<br />above Unless ,uc►i pOrbon has a permA in dr,, -_,-;h work tram the division
<br />❑ Divism of Industrlai Safety Permit ii
<br />I certify tical I have read this application and state that the above infnnrk loin is correct_ i agree to oomply witti all city and comfy
<br />ordinitnoft and statle laws relating to well construction and or laewage system Construction, and hereby sultiGnto rapresardatives of This
<br />caetmy to ether upon the above-mentioned pitiptiriy rnr inspection purpo_r�er;
<br />Dildo Applicant _
<br />FAD 43 <V 007 ti'_-0_N_'E_I; is(IN 1 HAr rrvis OK LARA fr*j
<br />e -..e-00
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