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JOB ADDRESS: PERMIT LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chapter 9 tct•mmcncing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License # F.xn -n— ' Date Contractor OWNER-BUILF)ER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 70315. 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 forsuch permit to file a signed statement that he is licensed pursuant to the provisions of Ilse Contractor's License Law (Chapter 9 (Commencing with Section 7(0X)) of Division 3 of the Business and Professions Codd or that he is exempt herel tum and the basis for the alleged exemption. Any violation of Section 7731.5 by any applicant for a permit subjects the applicant to a civil penalty of nor more than five hundred dollars ($500)): ❑ ],as owner of the property, or my employees with wages as their Sole compensation, will do the work, and the structure is nor intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of prupeny who builds or improves Ihercon, 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 cite year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) ❑ 1, as, owner of the property, am exclusively contracting with licensed contractors to construct the prtfject (Sec. 7044, Business and Profession Cade: The Contractor's License Law does not apply to an owner of property yho builds or improves Thereon, and who contracts for such projects with a contructnr(s) licensed pursuant to the Contractor's License Law,) 1:11 am exempt under Sec. „ B & P.C. for this reason I Date Owner WORKERS' COMPENSATION DECLARATION 1 hereby affirm that h have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (See. 3800. Lab. Q. Exp. Dare _ Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the County Building Inspection Division CERTIFICATE; OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed, if the permit is for one hundred dollars f$100) or less) 1 certify that in the performance of the work for which this 1Y.-r7llil is issued. I shall not employ any person in flay manner so As to become subject tot he Workers' Compensation Laws of California. Dale Applicant NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revnked, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending Agency Ior the performance of the work for which this permit is issued (Sec. 3097, Civ. Q. Lender's Nattte Lender's Address DIVLSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 111 hereby certify that no excavation five (5) or mom feet in depth into which a person is required to descend, will be make in connection with work authorized by the permit, and that no building structure, scaffolding r:dsea Ark, or demolition or disman ling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2,,6.n 2, Sec 341. Title 8, C.A.C.). ❑ As owner -builder, T will not employ anyone to do work which would rc•qune a permit from the Division or Industriul Safety, as noted above, unless such person has a permit to do such work from the division. E3 Division of industrial Permit No. 1 certify that 1 have read this application and state that the shove information r correct. I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. Date Applicant