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JOB ADDRESS: LICENSED I hereby affirm that I am licensed under the provisions of C Professions Code and my license is in full force and effect. License # L) Date )L I Z IZI_ I Contractor OWNER -BU I hereby affirm that I am exempt from the Contractor's License L Code: Any city or county which requires a permit to construct, also requires the applicant for such permit to file a signed state License Law (Chapter 9 (commencing with Section 7000) of D herefrom and the basis for the alleged exemption. Any violatior to a civil penalty of not more than five hundred dollars ($500)): ❑ I, as owner of the property, or my employees with wages intended or offered for sale (Section 7044, Business and P owner of property who builds or improves thereon, and who such improvements are not intended or offered for sale. completion, the owner -builder will have the burden of proving ❑ I, as owner of the property, am exclusively contracting with lic Professions Code (B&PC): The Contractor's License Law d and who constructs for such projects with a contractor(s) licer ❑ 1 am exempt under Section , B&PC for this r Date: Owner PERMIT #: DECLARATION with Section 7000) of Division 3 of the Business and Expiration Date oce- )30/0 3 iw for the following reason (Section 7031.5, Business and Professions alter, improve, demolish, or repair any structure, prior to its issuance, nent that he is licensed pursuant to the provisions of the Contractor's tision 3 of the Business and Professions Code) or that he is exempt of Section 7031.5 by any applicant for a permit subjects the applicant their sole compensation, will do the work, and the structure is not 'essioos Code: The contractor's License Law does not apply to an )es such work himself or through his own employees, provided that however, the building or improvement is sold within one year of at he did not build or improve for the purpose of sale.) sed contractors to construct the project (Section 7044, Business and s not apply to an owner of property who builds or improves hereon, �d pursuant to the Contractor's License Law.) WORKERS' COMPENSA I hereby affirm that I have a certificate of consent to self -insure or a ce thereof (Section 3800, Labo Code). / Expiration Date �¢ Z 12,2— Company �i I T— ❑ Certified copy is hereby furnished `Certified copy is filed with the Environmental Health Depatltmeiit CERTIFICATE OF EXEMPTION FROM N DECLARATION of Workers' Compensation Insurance, or a certified copy i ArT -r 'COMPENSATION INSURANCE I certify that in the performance of the work for which this permit i� issuedJ1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California, Date: Appl NOTICE TO APPLICANT: If, after making this Certificate of provisions of the Labor Code, you must forthwith comply with ; CONSTRUCT I hereby affirm that there is a construction lending agency for Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL ❑ I hereby certify that no excavation five (5) or more feet in connection with work authorized by the permit, and that no you should become subject to the Workers' Compensation ns or this permit shall be deemed revoked. AGENCY of the work for which this permit is issued (Section 3097, ,FETY PERMIT CERTIFICATION epth into which a person is required to descend, will be made in iilding structure, scaffolding, falsework, or demolition or dismantling