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JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirrn 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. l '
<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 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 /> 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 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 /> ❑I,tas owner of the property, am exclusively contracting with-licensed contractors to construct 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 contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section B&PC for this reason
<br /> r
<br /> Date: Owner
<br /> WORKERS'COMPENSATION 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 /> (This section need not be completed if the germit is for one hundred dollars($100)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 manner so as to
<br /> become subject to the Workers'Compensation Laws of Califomi . ,
<br /> Date: Applicant 4-
<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 forthwithcomply with such provisions or this'permit shall be deemed revoked.
<br /> I_ CONSTRUCTION LENDING AGENCY_' _ T ,
<br /> (
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIALAFETY,PERMIT CERTICATION '
<br /> ❑ I hereby certify that no excavation five (5) or more feet in depth into which,a person isorequired 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 /> ❑As owner-builder; I will not employ anyone to�do-work�which would require a permit from'ti Division-of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such`%ork'frorii the division.
<br /> ❑Division of Industrial Safety Permit# \'
<br /> I certify that I have read this application and state that the above information is�cgrrect.I;agree to comply w;th all-city and county
<br /> ordinances and state laws relating to well construction and or-sewige system con'stru&ion,and'hereby'authorize;representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-009 ` ` l 1 1 )i , '1 12/23/2003
<br /> Water Well Permit Contractor Declamction 4-02
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