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JOB ADDRESS:
<br />11F:ntll'I P.
<br />LIC'ENISVD CO\ I RAC TORS DECLARATION
<br />I hereby affirm tki I ant licensed urxiei the previswns of C hapn•d tl (cumn><nettig with Sc'ctxpt 7000) of Division 3 ofthe Buitness
<br />t and Professinr_s (-ode and my license ii in fill force and effeci
<br />Licentae N
<br />Date
<br />Expiration Datc
<br />Contractor
<br />OWNER -1131. 11 -DER DF:C:LAKA'l"110N
<br />1 hereby affirm that ! am exempt ftinn the Contractor, l.tcezisc Law for the following rcasar, (3ectior. 10:1.5, Auiineis and
<br />Ptofesatons Code: Any city ar Bounty w'btch require. a permit in comtract, alter. imprme, demolish, or repair any strucrure, ptiur to
<br />its issuance. also requires th; applicant for such permit to 131: a signed ciatenunit that he rs Licensed pursuant to the pTuristcns of the
<br />Contractor's license kaw (C'hapicr 9 (commcnnng with Se�aor ''Ot1t)) ofMv:ninr 3 of the Business and Professions Code) or that he
<br />is exempt hcreftnm aril the basis lin the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br />the applicant to a civil penally of not axtrc than rive hundred dollars (S5CNI1):
<br />El 1, as owner of lite protr'rty, or my employees with wagrs as their stile compensation, will do the work, ,nil rht• stn:ctnrc is not
<br />uttenried or nffcred for sate (Section 7044, Au4ibless and Piofessorns Code: Tke connector's License Law docs not ipp.y to an owner
<br />Of property Who Kid& nr iroprnvice thereon. and wbo docs such anti[ himself or c'rraagh his own emplayces, provideti that such
<br />intpravrrnents arc not imendcd or offc:ed for salt. If, ho Ae%ci. the bi:t(d[ng or unprmcnicni is sold within one rear of cumpletion,
<br />:ke owner-buildct will have the burden o, proving, That he d:tl nt>I build of improve for the prtposc of tale. )
<br />13 1, as owirr o lhr. piopetty, ate exclusrve•ly cuaracting wish licensed tonin rlois to construct the proles: {Section 7044, Business
<br />and Professions Code (B&PC)_ The Contractur's license Lau .:tics not apply to an owner of pro,,-.---rry who builds or improves hereon,
<br />and w•lut ctmslrucu fur such prikxts with a cmoracior(s) fiv%m-1c l pursuant to the Contractor's License Law )
<br />O 1 ate exempt i.ncks Section . R&PC fur ills. n•ison
<br />Dote:
<br />Ovp per
<br />WORKLRS' C0J1l'LN%A'I'1()ti DECLARATION
<br />1 hereby affirm that I have a ca-rtificate of ennsmt b self-insti-e. or a crntficatc of Workm` Cor licnsation insurance. of a cetlified
<br />Copy Ihrrecrf (SCLA ri 3800, Labin C'atk l
<br />Explratlon Date
<br />13 Certified copy is herehv tarnished
<br />D Certified copy is filed w•ilit rhe f nnrrnmen.al Hcalch De75annrent
<br />CF.RTIFIC'ATI: CIF EXEMPTION FROM WORKF.kS' COMPENSATION INSURANCE
<br />[This seelton reed rLQ1 b4 y&mV1dj:a11 .hc permit is for one Inct,lrrd dullars iT 1!:{)1 or less,
<br />1 ceftLfy [hal to the perftrrrmilct til' the- work fna wh rh 11114 rVi colt is is'turd, 1 shall not employ any perso:t sit any nt:.nncr :o as to
<br />becrimc iobjecl to the Workcrs' Compensation Laws ot" a:ifornta
<br />Date' Applicant
<br />NOTICE'. 10 APPLICANT- 11, alter snaking teas Cerlilir.tte of Lxrmptiun, goer should become su':jrct to the Workers'
<br />('urpm%atron provisions of the labor Coc!c, yutt muil fut'tiait:i cumply with such pros. isit-m or this permit dull he deetnrd revoked
<br />CONSTRUCTION LENDING AGE\C N'
<br />1 hereby affirm that there is a consirocuon lerdatg agency iia 11Le licrf+irrnanL%: tuf Cir work ler which this perm[ is issued (Section
<br />=097, Civit Cndc).
<br />l,rnder's Vane
<br />I,rmler' Addres.c
<br />DIVISION OF INDUSTRIAL SAFFIN PFRSITTCERTICATION
<br />D l Ieit•hy crritly rtac no excavation live (5) u: nun fect it. depth into whish a per%<n i, rcqu:Ted tit descend. will be rnrdc ir
<br />cortrttctiun with woait authorized h}- the permit, and that nu bu:rding structure. scaifoldu>,u. falsework, or demolition of dismantling
<br />thereof. w-tlt be mare than thirn•-six 00 fcrt hies- (Uhsptcr 3.2. Group ?. Article 2, SWRICI 341, Tills 6, Califuniia Administrative
<br />Code).
<br />O As owner-huilckt, T will not entploy anyone to do work wInch would Vgfurc u perm.,( Iiom Ibr 1ltvsstun of Lnduatrial Safety, as
<br />noted above, unless sucli perstm has. a permit to dei such nor'k bean tie clivi;ion.
<br />O Thvisirn of Indti-Arial Safety Permit
<br />I certify that 1 have lead this application and .1_w that the ohata infu:maaitm i% enrrect. l agree to ecirnply with ail CAV and cnunty
<br />ordinances and state caw, relsd,ng io well con amc-ion and or w%4-jW- syslvm v*omrucuun. and hereby authorize represcmativcs of This
<br />cowity to enter upor. the ,hove-mrmtnmcd ptupem' for inspccror. pmpmes.
<br />We
<br />Applicant
<br />tiHir 4 S-Iy?J•T LICE\ SLD WWRAf Tt?R S Df.CLARA TION
<br />11-11 e24o':
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