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FESBella PERMIT#: LICENSED CONTRACTORS DECLARATION licensed under the provisions of Chapter 9(commencingwith Section 7000)of Division 3 of the Business and my license is in full force and effect4130114 License# Expiration Data Date 8115113 Contractor V8W Orillin Inc. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and P%fe son Cod )or at exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any app' p ec !a the applicant to a civil penalty of not more than five hundred dollars($500)): ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale(Section 7044, Business and Professions Code: The contractors License Law does not apply to an rovided that owner of property who builds or improves thereon,and who does such work himself or through his own employees,p such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) Cl I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): The Contractors License Law does not apply to an owner of property who builds or improves hereon, and who constructs tor such projects with a contractor(s)licensed pursuant to the Contractors License Lew.) ❑1 am exempt under Section , B&PC for this reason Date: 8/15/13 Owner: WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to If e or a ce to of Wo vers'Compensation Insurance,or a certified copy thereof h( ectio 380 Labor Code). Expiration Date t/ Company\ Cl Certified copy is hereby furnished ertified copy is fled with the Environmental Heath Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed it the"" .m i is for one hundred dollars(S10O)or lest 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 Certificate of Exemption,you should become subject to the Workers' Compensation provisions of the Labor Code,you must forthvilth comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 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 connection with work authorized by the permit,and that no building structure,scaffolding,faksework or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2, Section 341,Title 8,California Administrative Code). ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Ind=Prowntatives d above,unless such person has a pert to do such work from the division. ❑Division of Industrial Safety Permit# I certify that I have read this application and state that the above information is conn agree to unity ordinances nd alas laws relating to well construction and or savage system ns 'o and rob utho' s county to am they ova-mentioned property for inspection purposes. Date Applicant LICENSED CONTFACTOR DECLARATION EHn 9307 hasty