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JoB ADDRESS: PrR.Mrr #:
<br />LICENSED CONTRACTORS DECLARA'T'ION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7G)-0) of Division 3 of the Business
<br />and Professions Code and my license is in full force and effect.
<br />License #
<br />Date
<br />Expiration Date
<br />Contractor
<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
<br />Professions Code: Any city or county which requires a permit to construct, aiter, improve, demolish, or repair any structure, prior to
<br />its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br />Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he
<br />is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br />the applicant to a civil penalty of not more Ulan five hundred dollars ($500)):
<br />❑ I, as owner of the property, or my employees with wages as their sole compensation, Aril] 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 owner
<br />of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br />improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,
<br />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 the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br />and 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 />❑ I am exempt under Section , B&PC for this reason
<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
<br />copy thereof (Section 3800, Labor Code).
<br />Expiration Date
<br />Company
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is filed with the Environmental Health Department
<br />CERTIFICATE OF E lEb4 PTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This section need not be completed if the permit is for one hundred dollars ($100,) or less)
<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:
<br />Applicant
<br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers
<br />Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section
<br />3097, Civil Code).
<br />Lender's Name
<br />Lender' Address
<br />DIVISION OF INDUSTRIAL SAFETY PFRNIIT CERTICATION
<br />❑ I 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 8, California Administrative
<br />Code).
<br />0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as
<br />noted above, unless such person has a permit to do such work from the division.
<br />❑ Division 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 construction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon the above-mentioned property for inspection purposes.
<br />Da
<br />Applican
<br />EED 43-02-007
<br />12/5/2002 MASTER Water Weft permit Contractor 1lccla,3Ctjcc
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