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JOB ADDRESS: T O O /yAtA0V �"' PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is In full force and effect.
<br /> License# `✓+S7�1/ Expiration Date 7�S iAge-a.)-a.)p
<br /> Date // Z.20';/ Contractor CpN E�� SDAt-� /'u e•
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Any city or county which requires a permit to construct, alter, improve,demolish,or repair any structure, prior to Its Issuance,
<br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's
<br /> License Law(Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any appllcanj for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars($500)): -
<br /> ❑ I, as owner of the property, or my employees with wages as their sole compensation,will do the work, and the structure Is not
<br /> Intended or offered for sale(Section 7044, Business and Professions Code: The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees, provided that
<br /> such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or Improve for the purpose of sale.)
<br /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or Improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section B&PC for this reason .
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy
<br /> thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> Certified copy Is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed If the permit is for one hundred dollars($100)or less)
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to
<br /> become subject to'the Workers'CompensatiortLaws of California.
<br /> Date:, Applicant
<br /> NOTICE TO APPLIdANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br /> prgvislons of the Labo?Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I herebx affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section 3097,
<br /> CIviPCode),. '
<br /> Lender'.yarpe
<br /> Lender's Address
<br /> I
<br /> •,�ti I.,,�r, DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby,peftthat no excavation five (5) or more feet in depth into which a person is required to descend, will be made In
<br /> connection wi(( work authorized by the permit, and that no building structure, scaffolding,falsework, or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high. (Chapter 3.2, Group 2, Article 2, Section 341,Title 8, California Administrative
<br /> Code).
<br /> ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted I
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHO 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> 6-26-08
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