|
JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License#_ Expiration Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that be is licensed pursuant to the provisions of the
<br /> Connector's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of rot more than five hundred dollars(3500)):
<br /> O 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is art
<br /> intended or offered for sale(Section 7044,Business and Profession Code:The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> such improvements we not intended or offered for sale. If,however, the building or improvement is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professitmi Code(B&PC): The Contractors License Law does not apply to an owner of property who builds or improves
<br /> hereon,and'Who constructs for such projects with a centractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'CONTPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (mss section need not be completed if the permit is for um hundred dollars($1001 or less)
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any ntatnef W u to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENC� j
<br /> I hereby affiun that then is a construction lending agency for the perfomnne,of the work for which this permit is issued(Section..,.
<br /> 3097,Civil Code). —
<br /> Lender's Name
<br /> Lender'Address .
<br /> DMSION OF INDUSTRIAL SAFETY PERMIT CEIjTICATION
<br /> 0 I hereby certify that no excavation five(5)or more feet in depth into which a person is required to dcicend, will be made in
<br /> connection with work authorized by the permit,and that no building sinicture,scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Croup 2,Article 2,Section 341,Title 8,California Administrative
<br /> Code).
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> I certify that I have read this application and state that the above information is correct I agree to comply with all city aid county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> Ivnnoof
<br />
|