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JOB ADDRESS: PERIVITT#•
<br /> Y
<br /> CA2 Z,
<br /> LICENSED CONTRACTORS•DECLARATION
<br /> 14[hereby affirm that I at`i�li•�en�d u he�rrovisions of Chapter 9(co>��ing uh Section 7000)f Division 3 of the Business and Prof6 ionns C,
<br /> and my license is in f 1 f e ect.
<br /> )0 ". _-!!�
<br /> ' License# yy Exp.:Date
<br /> Date
<br /> �� -y` 'L� ��)� •�''S SF'•L'' ��/�WUCLA -i0� ,�y'L�'� 4�' ',
<br /> I hereby affirmmFForre Contractor's License Law/or � tea (Seu!]031.5,Business and Professions Code; Any city or
<br /> po Cmy which requires a permit to construct,alter,improve,demolish,or repair a`n'y' lructure,prior to its issuance,also requires e� t for such permit
<br /> Q,. to file a si n ,fit that yynsed pursuant to the provisions of the Contractor's License Law(Chapter 9(commenci uh`5 on 7000)
<br /> -I Division 3 of�Bust�ess an Prdfes ions Code)or t e�Yt h9,e th r ($5'
<br /> d a ptioi L,Aexviolatio of Section 70- b
<br /> any applicant for a permit subjects the applicant to ally of not more tha five hundre otlars ($5 0)): w�/
<br /> '1�" ❑I,as owner r ro e y,f�m�employces wi ages as their �o satj iktli the work,and the st'T't is not i en offere sa3'
<br /> #15, (Sec.7044,Busilress an r s License Law nes naLaaa vuaan-o es t Creon,an w o
<br /> does such work himself or through his awn employees,provided that such improvement-'are tint intended or offered for sale. If,however,the building or
<br /> improvement is sold within one year of completion,the owner-builder will have the burden,of proving that he did not build or impro f e urpose of
<br /> `
<br /> sale.)
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<br /> f ❑I,as owner of the property,am exeZusively contracting with It go tors to construct the project(Sec'^7044�B�n�n ?hf�
<br /> 4 . Contractor' i d nota ly to an owner of prapert n d�or im t!!'>a_n,and who contracts for such projects with a contractors)
<br /> F licensed pursu�lto tlfe xUrAcense Law.) f
<br /> r ❑I am exempt U ;K, ccs a_-C
<br /> f¢J
<br /> t Date net
<br /> WORKERS�O PENSATfO4DEA TION
<br /> h by of it h 1 have a certificate of consent to self-insure,or a certificate oC m ensation I r c a cErtifi co tie of(pec.380jY
<br /> t� 4L alS , / — f i
<br /> any
<br /> � pi '-;y
<br /> ❑Certified c y h reby ur ed
<br /> ed-xytirtlte Crotirr tion DiviRion
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed,if the permit is for one hundred dollars($t00)or less) „
<br /> I certify that in the performance of the work for which this permit is issued,1 sJl.ill not employ any person in any manner so as to hecorne subject 11he/ :
<br /> Workers'Compensation Laws of California. �'�a
<br /> Date Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should becorrfe subject to the Workers'Compensation provisions of the !R
<br /> Labor Code,you must forthwith comply with such provisions or this it s rbe eemed revoked.
<br /> CONSTRUCTION LENDING AGF 'Y
<br /> I hereby affirm that there is a construction lending agency for the perform rk fnpu h t,is permit is issued(See.309"x,Civ. �� f '
<br /> Lender's Name
<br /> Lender's Address t
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> 0 1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in connection with work
<br /> authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet
<br /> high. (Chap.3.2,Grp 2,Art 2,Sep 341,Title 8,C.A.C.). `J
<br /> SS7 "y� n`ct,d
<br /> ❑As owner-builder,I will not employ anyone to do work which woul require a permit froni the Division ni itri)dus tial Safety,as noted a Y�tial uch'fc
<br /> person has a permit to do sucfi`work from the di�siq s
<br /> ❑Division of Industrial,perthil I4a:?
<br /> "c L catttfyithat 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws
<br /> "�c t rrl.tlnr;u►.aoU nayniaruruon
<br /> and at sewage sy mot►xlV= and hereby authorize representatives of this city to enter upon the above-mentioned property
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