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Jog Anonss: _ � PERMIT #- LICENSED CONTRACTORS DECLARATION I hereby affirm uim I nm Uc*naed under the provis-one of Chapter 9 jcammonaing *An Sect on 7000) of D.vslon 3 of tae Busncss and Prok""13 Cady and Fill tkans(o II I r- r ufloid p License b T Q� ETIraUon Oats �a Dau _Z? _ l 7 Ciontrac Y!r!f t J' OWNER -BUILDER DECLARATION I hereby offim that I em exempt from the Contractor's License Lew for the following reason (Section 7071 5. Busutess and Profam.ons Code Any city cr county which requires a permit to cerblruct, after, Improve demolish or repair any struclure prior to .is Issuance, also requtres the applicant for such permit to Oro a signed statement that he is licensed pursuant to the prov!sbns of the Contractor's License Law (Chapter 9 (commencing with Sacton 7000) of Division 3 of Ina Business and Professicns Coca) or that he is exempt herefrom and the basis For Ina eUeged exemption. Any vtolelron of Section 7031 5 oy any applicant for a permit subjects the apaIcanl to a civil pans of eel mare than fvo hundred do"ars ($500)): O f, as owner of Ine property, or my employees with wages as their sole compensation, will do the work, and the structure is not Intanded or offered ter sale (Section 7044, Business and Professions Code The ccntraupr's License Law does not apply to an owner of property who builds or improves thereon, and who does such worn himself at through his own employees, provided that such Improvements era not intended or offered far sole It. however, the budding or Improvement s sold within one year of comple±ion, the owner•bullder win nave the burden of proving that he did rot band or improve for Erie purpose of sale ) O 1. as owrwr al rhe property, am exclusively contract. ng With licorisad cnrrtraetors to Construct the project (Section 7044 Business end Professlcns Code (BdPC). The Contractor's License Law does not apply to an owner of property who bullds or Improves horaon, end who conalMets for such projects wish o contrsctogs) licensed pursuant to the Contractors Uunse Lew.) (3 1 am exempt under Section , BdPC for tris reason Data: Owner: WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certillcata of ceneent to self -Insure or a certificate of Workers' Compensation Insurance lir a Cori copy thereof ( rdfon3 Labor Lode). / Expiration Data Company 19OIZ ___ J©�(J o Certified copy is hereby fumished hearfined copy Is flied with the Environmental Healtr, Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ITII13 MCllon negg nW kit comdeted If the perlr it is for ono hundred dollars IS 1001Qr_e0 I certify that In the performance of the work for witch U,Is permit Is Issued ! shaft not amp': y any person in any manner so as to ba Come subject to the WorkersCornpensallan Laws of Ca'ifomla. Date:..___._,—...__......----_ APPltcnnt__ ___ NOTICE TO APPLICANT. Ifager making Ih,s Cer6fcata of Exempt . on, you anood become s•,tilecl la the Waxers' Componsat.on provisions or the Labor Codey;u must forthwith comply wan such provisions or this permit shall be doomed revoked. CONSTRUCTION LENDING AGENCY I hereby stram that there Is a constnrctlen :ending age-.cy lar the performance of the work for which this permit is issued (Section 3087, CIO! Code) Lender's Name Lander Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION CD hereby carldy trial no excavation fve (is a mon feel In depth nio which a Penson is required to descend wit be made In connection with work authorized by the permit. and that no ou tiding strurlt". weo:dingfafsewerk, or demolition at dismanuing thereof will be more then ltiatys x (36) feel high (Crispier 3.2 Croup 2. Article 2. Section 341, Tile a California Admin sirative Code) 0 As awner-budder will not employ anyone to do wok which woLdd require a permit from IN Mol -van of Industria Safely, as noted ebdve, unless such pardon nu a permit to 00 e0Cr1 wort from the division. O Owlsron of tnd.istnal Safely Psmill X I certify that I have read INIF application and state that the above information is correct I agree to comply with ai city and county ordinances and state few![ relating to Wait Construction and or sewage System consrNCl n. and 11 JIPr:rB a ntatrves of this ccurty to enter s0on the ama a cntonod property tar Inaaacdon purpose Dau % /r� - Applicant _. EMO 4MI uCENSeOCONTRACTOR DECLARATION taavor