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JOB ADDRESS: PERMIT#:
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<br /> `LICENSED CONTRACTORS DECLARATION 4
<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 my license is in full force and effect.
<br /> License# Expiration Date
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<br /> Date Contractor
<br /> ✓a 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 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 /> =x 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
<br /> usiness
<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 /> 1 and who constructs for such projects with 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 /> I hereb off rm that I have a certificate of consent to self-insure,or a certificate of Workers' Com ensation insurance,or a certified
<br /> t ecRhereb
<br /> a Cod
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<br /> :1it to mpan
<br /> ❑Cei fled copyh
<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 ' .4
<br /> I hereby affirn that there is a construction lending agency for the performance of the work for-which this permit is,issued,(Section
<br /> 3097,Civil Code).
<br /> Lender's Name t;.A e.
<br /> Lender' Address
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<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT.CERTICATION
<br /> ❑ 1 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 in
<br /> structure, scaffolding, falsework, or demolition or dismantling
<br /> thereof, will be more than thirty4ix.(36) feet high. (Chapter 3.2, Group 2, Art'ic'le-2, Section 341, Title 8, California Administrative
<br /> 'Code).
<br /> 1 ❑ 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 /> j `•A•� ter. 4
<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
<br /> ` ', � r . t
<br /> EHD43-02-007 "�` f ' ;12/23/24037
<br /> Water Well Permit Contractor Declaraction 4-02
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