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<br /> JOB ADDRESS: .. PERMIT#•
<br /> LICENSED CONTRACTORS DECLARATION y
<br /> (I hereby affirm that I,am•licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 o the Business
<br /> and Profess ons'Code and my ltceriss&is in full force and effect.
<br /> License# _ g' I `' Expiration Datel .i
<br /> Date - � 3 a,..j -s�, Contractor_ k = 1�',t '�''� �
<br /> �
<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, alter, 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 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 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 /> ❑ I, 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 Company -
<br /> Y ❑Certified copy is hereby furnished ,
<br /> ❑Certified copy is filed with the Environmental Health Department 4 \
<br /> CERTIFICATE OF EXEMPTION 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: Applicant
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you.:sliould 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 /> I 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 PERMIT 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 /> ❑ As owner-builder, I will not employ anyone to do work.which would require a permit from Itthe 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 /> Date Applicant ,
<br /> EHD 43-02-007 �� - f l 12/23/2003
<br /> Water Well Permit Contractor Declaraction 4-02
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