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FLIcense# S: i-13'tb 6t(wfobt�� 1/t. �SC4 IO✓1 PERMIT* LICENSED CONTRACTORS DECLARATION m that I am licensed under the ProV181oos of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Codeandmy license is In full force and effect. /�0�� Expiration Date I Z�3 i 1-7 Date_�7a(J b Contractor 2Ir V1fa 1 17r `i fin' OWNER-SUILDER DECLARATION I hereby affirm that I am P.xempt from the Contractor'S License Law for the following reason(Section 7031.5,Business and Professions Code: Any city or county which requires a permit b conaWCi,alter,improve,demolish,or repair any str0l](8.prior to Its ISsuBnce, also requires the applicant for such permit to file a Signed statement chat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter g(commenting with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt hererrom and the baste for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant b a OMI penalty of not mom than five hundred dollars($500)): ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the wed,and the structure is not intended or offered for sale(Section 7044,Business and Professions Code:The contrecors License law does not apply to an owner of properly who builds or,improves Hereon.and who does such work himself or through his own employees,provided that Such improvements are not Intended or offered for sale. If, however,the building or Impmvament Is sold within one year of _ completion,the owner-buiider kit have the burden of pmNrlg that he did not build dr Improve for the purpose of sale.) 1,as owner of the property,am exclusively Contracting with licensed conbactola to construct the pibtect(Sebe:"Bualnese and who connuctl for such YI Prol h a ntactar(s�licensed pursoes not uant to the W an Coonbacto 4 Lbanae Law-)Wrlw Of Pmwty Who Wide or Improves hereon, ❑1 am exempt under Section , BBPC for this reason WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-Insure or a certfidete,of Workers'Compensation Insurance,or a certited copy thereof(Section 3800,Labor Code). Expiration Date Company ❑Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completedif the nertnit is for one hundred dollars($100)or less) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If,after making this Certticate of Exemption,you should became subject to the Workers Compensation provisions of the labor Code,you must forthwith comply with such"alons or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perforinarlce of the work for which this Permit Is Issued (Section 3097,Civil Code). Lander's Name Landon Addrese - DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 I hereby cahtify that no excavation five($)or mom feet In depth Into which a person Is required to descend. will be made In connection wain m,K aulthortzed by the Permit,and thatnobuilding structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thkly six(36)feet high.(Chapter 3.2,Group 2,Amide 2.Section 341,TAIa e,California Administebw Code). ❑AS ownx-buibx,I will not employ anyone to do work which would require a permit from the Division of Indusidal Sanely,as noted above,unless such person has a permit to do such work from the dMsldn. C3 Division of Industrial Safety PermtS I certify that I have read this application and state that the above Information is correct I agree to comptywith as city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby ahthorhe representatives of this county so enter upon lire above-mentioned property for inspection purposes. Date Applicant uceisao wm9Acroa oecuawrron loDi3tlr 71WP7