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q .. q• aJ" +F.tfi JOB ADDRESS: L C, ,7 � �l� 7 „'S PERMIT#: W LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code andm license is in full force and effect. _ License# 773f Expiration Date 3� 4 d3 Date ID —;?A-02— Contractor _ -MA - OWNER-BUILDER DECLARATION I hereby affirm that=I am exempt from the Contractor's 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 Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects 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 contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own ertiployees, provided that 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.) ❑ 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 Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑I am exempt under Section_ B&PC for this reason Date: _ O r2— J '� Owner WORKERS' COMPENSATION DECLARATION 1 tzarPl,=,nffirm that r have a certificate of consent to self-insure, or a certificate of Workers' Compensation Insurance,or a certified I 11WN341'13m H3.1VM r13.LSVW Z00Z1U5 900-ZO-Etl OHd Gr .Oo� San C, d £ #QI IWM #aalonul #tsar as aau�aS ,t8 sY a Icua o u sa o �uaaa atpQ P u B J 1 p J /l, d pa�laasa aaq� tunowv JS 3d t3 —gtdaQ IIaM patan�isuo0 SINENW00 ate0 AS uoLtoadsul uoilau IS30 1 paniaaaB a3nlvM ❑ a1eQ AS uollaadsul dwnd 40I*Ulad IIaM 7VIJedS p ale(] AS uonaadsul tno10 aMo dmt � I P! V ea�v ,�� n AS paldaaav uoq=1ddy !� v V i V NOf 8 'LN L2ivd3Q