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L ADDRESS: PERMIT 8: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7(100)of Division 3 of the Business and Professions Code. and my license is to full force and effect. License k Exp:Dai Date Contiactor OWNER-BUILDER DECLARATION — 1 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.7031.5,Business and Professions Code: Any city or !I county which requires a permit to conswet,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 thr applicant to a civil penalty of not niore than five hundred dollars ($500)): 13 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 (Sec.7044.Business and Professions Code:The Contractor's License Law don not apply to an owner of property who builds or improves thereon.and who does such work himself or through his own employes,provided that such improvements are not intended or offered for sale. [f,however,the building or improvernent is sold within one year of compietion.the owner-builder will have the burden of proving that he did not build or improve for the purpose of , sale.) I ' _ O 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code-The 1 I Contractor's License Law does not apply to an owner of property who build,or improves thereon.and who contracts for such projects with a conraclnr(s) 1 licensed pursuant to the Contractor's License Lout f{ 13 1 am exempt under Scc. B&P.C.tri this realm I Date Owner _ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800, Lab.Q. I Exp.Date Company CI Certified copy is hereby furnished ❑Certified copy is Ned with the County Building Inspection Division I _ CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE Mis section need not be completed,if the permit is for one houdred dollars($100)or less) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject tot he Workers'Cumpensauon Laws of California. I Date. Applicant—_____� NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject tothe Workem'Compensation provisions of the Labor Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction Icnding agency for the performance of the worst for which this peraut is issued(Sec.3097,Civ.C). ` Lender's Name Lenders Address_ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑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 4 authorized by the permit,anu that no building structure,scaffolding.falsework,or demolition or dismantling thereof,will he more than thirty-six(,361 Feet i high. (Chap 3.2.Grp 2,Aa 2,Sec 341,Title 8,C.A.C.). 1 O As owner-builder.I will not employ anyone to do work which would regmre a permit from the Division of Industrial Safety,as noted above,unless such ` + person has a permit to do such work from the division. II Q Division of Indusinal Permit No. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and slam laws relating to welt construction and or sewage system construction.and hcrehy aurhurire representatives of this city to enter upon the above-mentioned property for inspection purposes. Date_ Applicant__ _ _ 'I