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<br /> JoB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that t am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is in full force and effect.
<br /> License# ?3 ,,9 3 F Expiration Date � ���/i U
<br /> Date ! 10=1 Contractor W.s f Loc,tf Sri, v E(eL,7l be-9 ��,�/e �-Lec�,I�
<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 Professions
<br /> Code: Any city or county which requires a permit 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 permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars($501
<br /> Q 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
<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 /> 0 t,as owner of the property,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 contractors)licensed pursuant to the Contractor's License Law.)
<br /> ©1 am exempt under Section , B&PC for this reason
<br /> Date: /v o r o 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
<br /> certified copy thereof(Section 3800, Labor Code).
<br /> I Expiration Date Company
<br /> Q Certified-copy'is-hereby furnished-
<br /> 0 Certified copy is filed with the Environmental Health Department
<br /> I
<br /> I 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
<br /> as to 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 /> f 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
<br /> (Section 3097,Civil Code).
<br /> Lenders Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> 1 1 hereby certify that no excavation rive (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 hkgh, (Chapter 3,2, Croup 2,Article 2, Section 341, Title S, California Administrative
<br /> Code),
<br /> I As owner-builder, I 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 /> IJ Division of Industrial Safety Permit#
<br /> I certify that 1 have read this application and stale 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 41-07 LICENSED CONTRACTOR DECLARATION
<br /> 7 D!5l07
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