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JOB ADDRESS: PERMIT,#:
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<br /> /LICENSED CONTRACTORS'DECLARATION�,
<br /> affirm
<br /> I hereby arm that I,am lic_Eriied'under the provisions of Chapter 9(commencing with Section 7000)of Division 31of the Business
<br /> and Professions Code and my license is in•full force and effect. r
<br /> \ 'Li- `c: f- Jt.�j t1. �4�! :! ,:?'rj .fit I
<br /> ' L�nse#-r--• . ._ _. _ Al I r i E,zpiratioh Date.
<br /> Date Contractor
<br /> 1 J,Ji, I.)cjJi
<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 /> ❑ 1,as owner of the property,or my employeei'with wages as their sole:compefisation,wilfdo'the.work,and the structure is note;
<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 /> ❑_I,ta .owner of the property,am exclusively contracting with licensed contractors twconstruct the project(Section 7044,Business,,
<br /> 6A,Professions Code(B&PC): The Cdfliractor's License Law-does not ripply for an owner of property who builds or improves A
<br /> hereon,and who constructs for such proje'ctspwith 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 /> r '
<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 /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health-Department r ,
<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— *-� r n
<br /> _ .`.
<br /> NOTICE TO APPLICANT-,If,'after malting 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 /> :
<br /> CONSTRUCTION LENDING AGENCY`
<br /> I Ii by affirm that there s a construction lending'agency forthe performance of the work for which this permit is issued(Section
<br /> 3097,Civil,Code). \� '�`�� _ ` ,• ` 1 .\
<br /> Lender's Name
<br /> Lender'Address71.
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> l l I hereliy eemfy.\hat no'excavation five(5j,or,more feet I.depth into Miich 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 /> 1,
<br /> thereof will lie`more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section_341 Title.8,.Califomia Administrative' "
<br /> Code •' `,• ,`
<br /> O owner-builder,I will not employ anyone to do work which would require.a_permit.from_.cite+Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do suchwork from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> ' I cerify 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 /> `LICE FHD43-02.007 �,NSE c r, ` 'D CONTRACTORSDECIARATION
<br /> 12/11/2002
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