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` JOB ADDRM.- PERMIT#:
<br /> ` LICENSED CONTRACTORS DECLARATION
<br /> I 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 /> 6o License# Expiration Dale
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATTON
<br /> 6. 1 hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031.5, Business and
<br /> Profusions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any Struchna,prior to
<br /> its issuance,also requires the applicant for such permit an file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> Vis 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 not more than five hundred dollars($500)):
<br /> ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> O 1,as owner of the property,am exclusively contracting with licensed contractors to mostruct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License law does not apply to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contraeton(s)licensed pursuant to the Contractor's License Law.)
<br /> 01 am exempt under Section , B&PC for this mason-
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> a. 1 hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
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<br /> E3 Certified copy is hereby furnished
<br /> O Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> r
<br /> (This section need not be completed if the permit is far one hundred dollars($I00)or lessl
<br /> I certify that in the performence of the work for which this permit is issued,I shall not employ any person in any manner so as in
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTIC TO,1 APPLICANT: If, after making this Certificate of Exemption, you should become subject te the Workers'
<br /> Comp,,' ,t'pn$uovisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hcme X_4[futrf,tlat there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097c9mil Code).
<br /> R.<g!
<br /> r_ Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> D I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend,will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding, falsework, or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative
<br /> Code)_
<br /> O 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 /> O Division of Industrial Safety Permit#
<br /> wo I certify that I have read this application and state that the above information is correct I agree in comply with all city and county
<br /> mdimnces 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 /> a. EHO 43-02-007 LICENSED CONTRACTORS DECL-JtAT[ON
<br /> 12/11/2002 )
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