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<br /> JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION,.
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and•myiicense-is in full force and effect:
<br /> License# Expiration Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 703 L5, 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 /> E _ ❑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,ora certificate of Workers' Com ens on e,o d
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<br /> 1p at mpa
<br /> ❑C ified cop her is
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<br /> ❑Certified copy is filed with the Environmental Health Department
<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 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 /> CONSTRUCTION LENDING AGENCY
<br /> }
<br /> I hereby affirm that there is a construction lending agency for the performance ofthe work for which this permit is issued(Section
<br /> 3097„Civil:.Code.): r
<br /> Lender's Name
<br /> Lender'Address 'r
<br /> ' M
<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 the 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 r
<br /> EHD 43-02-007
<br /> Water Well Permit Contractor Declaraction 4-02 12/23/2003 1.
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