|
a
<br /> JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 Om licensed under he provisions of Clspw,9(commencing with Section 7000)of Division 3 of to Buainm,sad Pmfssslms Code,
<br /> and my license is in full force and effeet.
<br /> License N Exp,:Dam
<br /> Dam Comscror
<br /> i
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 am exempt from the Comranor's Licc"se law for the following reason(Seo.70313.Business and Psora rain Code;Any city or
<br /> county which mquims a permit to comtmet,alter,improve,dont-hath,or repair any structure,prior m its issuance,els.regmroa the applinm far su,S permit
<br /> to file a signed statement that he is Uccmod pursuant to the provisions of the Contractcu s License law(Charger 9(commencing with Section 7010)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt henOrmm and the basis for the alleged exemption. Any violation of Section M31.5 by
<br /> any applicant for a perm"[subjects the applicant m a Civil Penalty of net more than five hundred dollars
<br /> 0 1,as owner of the proPary,W my emoloyeos with wages as;their auto compensation.will re the work,end the structure is rent"mend d or offered for We
<br /> (Sec.7044,liminess and Professions Code The Contractor's License Law does not apply to an owner of property who builds or improver thereon,and who
<br /> does such work himself or through his own employees,provided that such improvements arc na intended or oSared forsale. IL however,the building m
<br /> improvement is sold within ane year of comphdloa,the owner-builder will have the burden of proving that he did no,build or improve for the impose of
<br /> sale.)
<br /> ❑1,as owner of the property,am exclusively Conbrading with licensed conu¢tors to c.nstrod the project(Sec.7044,Busincu and Profession Code:no
<br /> Contractor's U...Law does not apply man.umorof properly who build,or improves thereon,and who contracts for such prajcers with a conlracbu(s)
<br /> licensed pursuant In the C.n mcusCs Uccnw Law.) -
<br /> ❑I un exempt under Sec. ,D A P.C.for thio reuwn
<br /> Date Owner
<br /> W OREERS'COMPENSATION DECLARATION
<br /> 1 hereby affirm that I have a eenifiwle of consent to sclGinsure,or a,zr,iftcate of Workers'Compensation Insurance,or a ceniried copy thereof(Sea 3800,
<br /> Lab.C).
<br /> Exp.Date Company
<br /> E3 Cenified copy is hereby furnished
<br /> 17 Cortificd espy is filed with the Ca..ly Building inspection Division
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed.if the permit is for one hundred dollars(5100)or Icas)
<br /> 1 certify that In the P-1—nce of the week for which th s permit is issued,I shall nm employ,any person in any mrnner so as to become subject 10 the
<br /> Worker"Compenswion Laws of California.
<br /> Date Applicant
<br /> NOTICE TO APPLICANT.IL all.making this CorLficaue of Exemption,you should became subjet i to the WOrkoot Compcnsmion provisions of the
<br /> labor Coal',you must forthwith comply with such Provisionsor Nis permit shall be doomed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that them is a cominsaton lending ageney fur the performance of the work for which this permit is issued(Sec.3097,Civ.Q.
<br /> l.cndcr a Nana
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION-
<br /> 0 f hemby certify that an axcarsdon fila 0)car mote feet in degh into which a Person is no,amd to descend,will be make in connection with work
<br /> authorised by the permit,and that no building structure,scaffolding,falacw.rk,or demolition or dismantling thereof,will be more than shiny-six(36)feel
<br /> high. (Chop.3.2,Grp 2,An 2,See 341.Titic 8.C.A.C.).
<br /> ❑As owner-0uildor,1 will not employ anyone r0 do work which would require a permit from the Division of Industrial Safety,as resod above,unless such
<br /> person has a poloul10 do such work from the division. _
<br /> ❑Division Of IndeRrial Permit No.
<br /> l ocrtify that I have road this application and store that dm above iofomution is Crrrm, I egret m mmply wish all city ane counsy ordinances and aorta lows
<br /> relating to well contraction and or sewage system constme[lan,and hereby amhome roPmoor o ves of this County m mmr upon tae above-menlioned
<br /> property for inspection p posts.
<br /> Gale applicant
<br />
|