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Jos A LICENSED I hereby affirm that I am licensed under the provisions of Cl' Professions Code and my license is in full force and effect. License # Date Z Z 2 Contractor PERMIT #: DECLARATION 9 (commencing with Section 7000) of Division 3 of the Business and OWNER-BUILIDER D Expiration Date T 'Q G� �.C. 67 . I hereby affirm that I am exempt from the Contractor's License haw for the following reason (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct,alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed stat ment that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for the alleged lexemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): ❑ I, as owner of the property, or my employees with wages qis their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and professions Code: The contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ I, as owner of the property, am exclusively contracting with lic nsed contractors to construct the project (Section 7044, Business and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Section , B&PC for this reason Date: Owner, WORKERS' COM PENSA I hereby affirm that I have a certificate of consent to self -insure or a thereof (Section 3800, Lbor Co ). Expiration Date �, 22 Company iD�a ❑ Certified copy is hereby furnistied Certified copy is filed with the Environmental Health Department DECLARATION of Workers' Compensation Insurance, or a certified copy es Ac T t CERTIFICATE OF EXEMPTION FROM �ORKERS' COMPENSATION INSURANCE I certify that in thej performance of the work for which this permit i4 issu become subject to the Workers' Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex mpt provisions of the Labor Code, you must forthwith comply with such pro, CONSTRUCTIO I hereby affirm that there is a construction lending agency for the Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL! ❑ 1 hereby certify that no excavation five (5) or more feet in connection with work authorized by the permit, and that no shall not employ any person in any manner so as to you should become subject to the Workers' Compensation is or this permit shall be deemed revoked. AGENCY of the work for which this permit is issued (Section 3097, MIT CERTIFICATION which a person is required to descend, will be made in icture, scaffolding, falsework, or demolition or dismantling