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' JOB ADDRESS: PERMIT B:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hucby affirm Nat l azo llcensad underibe provisions of LTapter9(wmmocing witlr 5«tion 7000)of Division 3 of the Busicess arefPmfessiona Cade,
<br /> and my license is in full fora and effect.
<br /> Licenun_ Exp.Da
<br /> Daze Convector
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affrm Ihaz I am c¢mpn from the Conmcmr's Liceex law for the fallowing reason(Sec.703LR Business and Pofesi0m Code: Any city or
<br /> county which mquires a permit to censwcs alter,improve,demolish.Or repair any structure,poor m its isaumce,also mr tinea OR applicant for such permit
<br /> m file a signed statement than Is;is licensed pursuant to the provisions of the Coommiar's License Law(Chaprer9(commenting with Section 7001))of
<br /> Division 3 of the Business said Milestones Code)activist he is exempt hereham and rhe bis for the alleged exemption. Any violation of.Section 70315 by
<br /> any applicant for a pends subjxk the applicant in e civil penalty of lust seems than five hundred deBma ($5w)h
<br /> _ 01,m--Of the property,m my employee with wages m Nee sok comperwazim.will de the wort,sued ted move.is nm intended or offered for We
<br /> (Sec.7041,Busiteas mat Professions Gds:no Consensus's Lt.Law does not apply to an owner of propmy cob,builds or impmves theram.and whu
<br /> dapssuchworkwidwiersloughhisawnemployees,providedshatsuch ihp crtW n ndiAngd amofferedforsale. IL however,thebuilding f
<br /> ask.) mem is sold within one yea of completion,the ownerbailda will have the WNcn of poving that!e did std buildmimprove for she pumde of
<br /> sale)
<br /> 0 L se crafter of the propemy,am exclusively conaaaming with limmml opntramers tocansWct the project(Sec.70/4,Business and Profession Code:The
<br /> Contractor's License law doe net apply no an owrcr ofpropmy who builds or improves thereon,and who contrite for such projects with a Lrontrisnr(s7
<br /> licensed Pursuant m the Commer's laccmc Law.)
<br /> O l am carmps under See ,B R P.C.for this mason .
<br /> Date Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a cenificam,aconsent to cclf-insure,or a ccnificate Of Workers'C .,we mcaa Insurance,Or a attified copy thereof(See ISM,
<br /> Lab.Q.
<br /> Exp.Data Company
<br /> O Certified copy is hereby faotahra
<br /> O Certified copy is filed with the County Building Inspection Division
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section nmd not be completed if the perrrds is for one harassed dollars(SI Off)Or less)
<br /> I ratify than in the pertotnnaie of red ,it for which Nin pemm is imuiI shall not mi my person in any manna so as to bectime subject ort be
<br /> Workers'Compensation Laws of Cali forma.
<br /> Dore Antitrust
<br /> NOTICE TO APPLICANT:If,of o,making this Cer ifiuR oflixemptim,you should become subject m the Workers'Compensation provisions of she
<br /> Labra Cock,you must forthwith.comply withsuch provisions err this permit shall h deenwd Rvuked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I herMy affirm that them is a eonsbuclion lmM% agency for the per!nce,a Ne work for which this pereit is umed(Sm.30 a'y,Civ.C).
<br /> Lender's Nnme
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> 0 I botchy certify that n0 excavation five(5)or mom feet in depth lona which a oamn is requhed an dacerd,will be make to connection with wml,
<br /> authorized by the permit,and then an,building scommo,scaffolding,felnework,or demolition or dismantling thereof,will be,nee,than thirty-six(36)het
<br /> In& (CMp�3.2,Grp 2,An 2,Sec 341,Mile 8,C.A.C.),
<br /> 0 As owner-builder.)will nor employ anyone to do work which would require a permit from Ne Division of Industrial Safety,as noted above,unless such
<br /> person has a front to d0 such work from the division.
<br /> ❑Division of Industrial Perrin,No.
<br /> ]aenify that l lave read this application and ante thatthe above infometi0n is comet, l norm m comply with ail city and ca intY ordinates and rreh kws
<br /> mining to well ccrnsmmtion and Or sewage systemconmuction,and hereby=boom repreuntnives of this city meow upon the abovo-mmdaned WPerry
<br /> for insprcrion impasse.
<br /> ... •• bek ' Applicant _
<br />
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