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<br />.toe ADDRESS: ""� m"M�t �. ,('9/VV 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 and
<br />Professions Code and my license is in full force and effect.
<br />License # ice' `7 " l�`a%►� X41 Expiration Date 'S 3112 a/ Z
<br />Date IZ2 Contractor
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<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 Professions
<br />Code: Any city or county which requires a permit to construct, Biter, improve, demolish, or repair any structure, prior to Its Issuance,
<br />also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's
<br />License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he is exempt
<br />herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br />to a civil penalty of not more than rive hundred dollars ($500)):
<br />❑ I, as owner of the property, or my employees with wages as their sole compensation, wilt 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
<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 />111. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br />Professions Code (B&PC): The Contractors License Law does not apply to an owner of property who bullds or improves hereon,
<br />and who constructs for such projects with a contractor(5) licensed pursuant to the Contractors License Law.)
<br />❑ 1 am exempt under Section , BRPC for this reason
<br />Date:
<br />Owner:
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a
<br />certified copy thereof (Section 3800, Labor Code).
<br />Expiration Date �3 Company
<br />❑ Certified copy is hereby furnished
<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 (S 100Zor Jess)
<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
<br />as to become subject to the Workers' Compensatlon Laws of California.
<br />Date:
<br />APP
<br />NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br />provisions of the Labor Code, you must forthwith comply with such provisions or this permit shell be deemed revoked,
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued
<br />(Section 3097, Civil Code).
<br />Lender's Name
<br />Lender' Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />❑ I hereby certify that no excavation live (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 thfrty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, Calitomle Administrative
<br />Code).
<br />❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted
<br />above, unless such parson has a permit to do such work from the division,
<br />❑ Division of Industrial Safety Permit ri
<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
<br />EHD 43-67
<br />IWW7
<br />Applicant
<br />LICENSED CONTRACTOR DECLARATION
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