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12/14/2012 10:21Canepa & Sons (FAX) P,005/006
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<br /> JosADDRESS: eZ0�0 2 L7�OILl PERMIT#:
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 am licensed under the provisional of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> IProfessions Code and my license is in full force and effect, //
<br /> License# p�J Expiration Date -7 Expiration
<br /> Date /�l/�a f/¢°,3 Contractor) /V e A-'' SOw S i fir C.
<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 10 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 Contractors
<br /> License Lew(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 Soction 7031,5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than Ave hundred dollaral(5500))
<br /> ❑ I, as owner of the property, or my employees with wages as Choir 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 muter-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 excluslvety contracting with licensed contractors to construct the projec:(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 Lew.)
<br /> ❑I am exempt under section B&P.0 for this reason
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
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<br /> I hereby affirm that I have a certificate of consent to self-Insure or a certlflcate of Workers'Compensation Insurance,or a certified copy
<br /> thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy Is hereby furnished
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<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 hundro�dQJI rs(51001 or Icssl
<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'Compensation Laws of California.
<br /> Date: Applles"a
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permit shell be deemed revoked_
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued(Section 3097,
<br /> Civil Code).
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in
<br /> connection with 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 6, California Administrative
<br /> Code). I
<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
<br /> above,unless such person has a permit to do such'work from the division.
<br /> ❑DIVIslon 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 constructlon land or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property foq inspection purposes,
<br /> Date Applicant
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<br /> EHD 43.02-00Y LICENSED CONTRACTORS DECLARATION
<br /> 626-08
<br /> Received Time Dec, 14, 2018 10 : 19AM No, 4480
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