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12l01'''205 14: 05 '094E5;' -PE:=:TRI_Ih1 EXPLOTIOh! PAGE F�3
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<br /> .1QH At)URl{.SS: ✓ V , U' '`'J �� PERM1iIT'#: 51+.
<br /> i,IMSF..T3 CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 70(10)of Division 3 of the Business
<br /> and Professions Code and any license is in full force and e(Tect. �/ y
<br /> Ucemeo 5:(;.2(0!3 Expiration Date -7
<br /> Date f -G'-o r Contractor 5fSCT0l!0ey1 llRCderA-"0AJ.,, Iry
<br /> OWNER-B[fIC 1)FR DECL*RATION
<br /> I hereby affirm that I am cxcmpt horn the Contractor's License Law for the following re1KAn(Section 7031,5, Business and
<br /> Professions Code: Any city or county which require%a pmmit to construct,alter,improve,demolish,or repair city struct m,prior to
<br /> its issuance,also requires the applicant for such pcmrit to file a signed statemem that he is licenced 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 thru he
<br /> is cxcrlpt hcrufrnrn and the basis Cor the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjcm
<br /> the applicantto a civil penalty oftlot mo than five hundred dollars($5WY)'
<br /> L]1,as owner o£the property,M my employees with wages as their sole compensation,will do the worm and the stnicb.rre is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an
<br /> owner of property who builds or improves there m.And who does such work himself ar through his own employees,provided that
<br /> such improvements are not intended or offered far sale. If.however,the building or improvement is sold within one year of
<br /> completion,tic owncrvbuilder will have the burden of proving(hat,he did not build or improve for the purpose of sale.)
<br /> O E.w owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Rusiness
<br /> and Prufcssiuns Code(P&PC): The Contractor's Liretrse T-aw does not apply to an owner of property who builds or improves
<br /> beneotr,and who to sllmcts for such pnsjecta with a contractor(s)Iiccnsod pursuant to the Contractor's License Law.)
<br /> 01 am exempt under Section 13&PC for this reason
<br /> Daft: Owner
<br /> WORKERS'COMPENSATION DECIARATTON
<br /> T hereby affirm that I have a certificate oFtomseni to self insure,ora certificate of Workers'Compensation Insurance.of a certified
<br /> copy thereof($ection 3800,Labor Code)- _
<br /> Expiration Date -�d-L7�O Company_J*f��{ C/O tqJ FAX a �I�f J 9 AAJ C--e
<br /> 17)Cerrtified copy is hereby finished
<br /> PrCerlirfied.Copy is filed with the Environmental Health Department
<br /> CERTIFICATR OF FXRMPTION FROM WORKERS'COMPENSATION 1N.C7rRANCE
<br /> fThis section need not he comyletcd if the permit is fof„og Jltmdi Ldollars(S 1001 or I—
<br /> I certify that in the perfvtmance of the work for which this permit is issued 1 shall not employ any peMM in any manner so as to
<br /> become suh{erl',to the Workers'Compensation Laws of California
<br /> Date: Applkiiiot
<br /> NOME TO .APPLICANT: if, after making this CmiCic= of Exemooa, you should become subject to the Workers'
<br /> Compensation provisions of the 3'tbor Code,ym must forthwith comply with such provisions or this perms shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGFNCV
<br /> i hereby affirm that them is a construction lending agency fat the performance of the work for which this permit is issued(Section
<br /> 3(197,Civil Code).
<br /> Lender's Name
<br /> Leader'Addren
<br /> 1"STON OF 1NDI)STRiAL SAFETY PERMIT CEIfCI'ICATION
<br /> pl T hereby certify that no excavation five(5)or nacre 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,falwwadc,or demolition or dismnntli ng
<br /> eo
<br /> therf,will be more than thirty-six(36)feet high.(Chapmr 32,(roup 2,Article 2,Section 341,Title 8,Califnmia Administrative
<br /> Code),
<br /> L]As owner-Imildcr,1 will not employ anyone to do work which would require a permit from the Division of Tndustrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> Division of Industrial Safety Permit#r__..,n__
<br /> 1 certify that i bmvr.read this mmlicatiem and.tato that the above information is correct.T ngmc to comply with all city and county
<br /> oxdinrnces knd slate law%relating to well construction and or sc"ge system conctnrctimr,and hereby authorize mprescntstives of this
<br /> county to enter t.pon the shove-mentioned property for inspection purposes.
<br /> Date 1.2 -`q-QT Applicant
<br /> FTM—r'2— 7 LTCHNSM COia'r :4;R TITUM.AttAT(4N
<br /> 1 Jt I12Qa:
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