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12/14/2018 10:20 Canepa & Sons
<br />Received
<br />(FAX) P. 003/006
<br />i
<br />Joe ADDREeet a a -72 S 6 1_,Poe /F 4J 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 />Professlons Code and my license Is In full force and effect.
<br />License# .2Z7 Expiration Date
<br />Date Contractor. dRtik,04 /IV 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 />Coda: Any city or county which requires a permlt 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 applicant for a permlt 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 7034, Business and Professions Code: The contractor's License Lew 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 />❑ 1, as owner of lho properly, 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 em exempt under Section S&PC for this reason
<br />i
<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 3500, Labor Code),
<br />Expiration Date Company
<br />O Certified copy Is hereby furnished
<br />O Certified copy is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This scctlggccd not be comoi I if th_e_permft,is for one hundred dollars ($100) or leas)
<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: Applicant
<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 provlslons or this permit shall 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 />M 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 then thirty-six (36) feet high. (Chapter 3,2, Group 2, Article 2, Section 341, Title A, Callfornla Administrative
<br />Code).
<br />❑ As owner -builder,.) 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 />❑ Division of Industrial Safety Permit #
<br />1 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 properly For: inspection purposes.
<br />i
<br />Date Applicant
<br />CHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br />6.26.09
<br />ime_Dec. 14, _2018_10:19AM—No, 4480
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