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r: - JOB ADDRESS: PERMIT LICENSED CONTRACTORS DECLARATION I hereby affirm that tam licensed under the provisions of Chapter 9 (Commencing with Section 7000) of Division -3 of the Business and Pnnfcssions Code, and my license is in fall force and effect. License p Exp,:Daie Dale Contraclor OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's Uccnsc law for the following reason (Sec. 7031.5, Busincas 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 penAL to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Soctimn 7000) of Division 3 of the Business and Professions Cndc) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not marc than five hundreddollars ($500)): ❑ I, as owner of the property, or my employers with wages as their sole compensation, will do the work, and the structure is not intended or Offered For sale 1Sec. 7044, Business and Professions Code: The Coatracloi s License Law docs not apply Loan owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such )mprovements are not intended or officmd 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 be did not build or improve for the purpose of sale.) O Las owner of thero p prny, am exclusively contracting with licensed contr-uclors to construct the project (Sec, 7(94, Business and Profession Curie: The w Contractor's License Law docs not apply Loan owner of property who builds or improves thereon, and who contracts for such pTiccls with a Coatra a Ile licensed pursuant to the Contractor's License Law.) ❑ f am exempt under Sec, , B & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-iasu re or a certificate of Workers Compensation Insurance, or a certified copy thereof (Sn. 38g1, Lab. C). Exp, Date Company i ❑ Certified copy is hereby furnished I . ❑ Ceni Gcd 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 ($100) or less) 1 certify that in the performance of tltc work for which this permit is issued. I shall rot employ nay person in any manner so as to become subject to the 1 Workers Corrpcuation Laws of Califo$ria. Date Applicant NOTICE TO APPLIGINT; If. after making this Cenificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you Must forthwith comply with such provisions o` this permit shall be doomed revoked - CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency foi the performance of the work for which this permit is issued (Sec. 3097, Civ, Q. Lender's Name Lender's Address DIVISION OF INDUSTRIAL SACETY PERMIT CERTIFICATION: D I hereby certify that no excavation five (S) or more 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, falsework, or demolition or dismantling thereof, will be more than thiriY-six (345) fact high. (asap. 3.2, Grp 2, Art 2, Sec 341, Tide 8, C-A.C.). - tutµ not employ anyw c lode work which would mqunm a permit from Ute Division of Industrial Safety, as noted above unless such personitasa ptvdvsactrworkhonrthcdivtsiots - - - _�--.-----.--_.--.._ _..._...- -. h . ❑ Division of industrial Permit No. 1 cert)fy that] have read this application and state that the above information is coria. I agree to comply with All city and county ordinances and state laws relating [Dwell construction and or sewage system construction, and hereby authorize repreacntntives of this county to enter upon the above-nrntioned property for inspection purposes.