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JOB ADDRESS: PERMIT#. LICENSED CONTRACTORS DECLARATION I hereby affirm that I um licensed under the provisions Of Chapter 9(commencing with Section 7000)of Division 3 of the Busint_"and Professions Code. . and my license is in full force and effect. License* Exp.:Date Date Contractor OWNER-BUILDER DECLARATION I hereby uffirm that I am exempt Gam the Conlractar's License Law for the following reason(Sec.7¢31.3.Business and Professions Code;Any city or couMY which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its isauanaa,also requires the applicant for such permir to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commenting with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefmm and the basil for the allegod exemption. Any violation of Section 71131.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars WOOD: Ii ❑has owner of the property,or my employees with wages as[heir sole compensation,will do the work,and the arrucrure is nor intended or offered for sale � (Sec.70.14,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 awn emproyces,provided that such improvements are not intended or offered for sale, If,however,the building or improvement is sold within one year of con:ok[ion.the owner-builder will have[he burden of proving that he did not build or improve for the purpose of j sale.) ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7644.Business and Profession Cade'-Thr Contractor's License Law does not apply to an owner of property who builds or improves thereon.and who contracts for mach projects with a eontraclar(s) licensed pursuant to the Contractor's License Law,) 13 1 am exempt under Sec. .B&P.C.for this reason Date Uwncr - WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate orconsent to self-insure,or a certificate of Workers'Compensation Insumnee.or a certified copy thereof(Sec.Mfxt, Lot.C). Gap.Date__Company i 0 Certified copy is hereby furnished ©Certified copy is riled with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed,if the permit is for one hundred dollen($100)or less) [certi ry that in the performance,or the work for which this permil is issued.I shall not employ any person in any manner so as to become suhject rot he workers'Compensation I-aws of Califomia, 031e Applicant ' NOTICF,TO APPLICANT:If.after making this Ctttirieate Of Exemption,you should become subiect to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions w this permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency far the performance of the work for which this permit is issued(Sec.30197,Civ.C). Lender's Name Lender's Address 1 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 0 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 cronm;Udon with work authorized by the permit,and that no building strucrure.scaffolding,falsnwork,or demolition or dismantling thereof,will be more than shiny-six(36)feel high. (Chap.3.2.Grp 2,?n 2,Sec 341,Title S.C.A.C.)- ❑As owner-huildcr,1 will not employ anyone to do work which would require a hermit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. ❑Division or Industrial Permit No. I certify that t have read this application and state that the above information is correct, 1 agree to comply with all city and county ordinances and%talc laws relating to well construction and or sewage system construction,and hereby authorize rcri sentalives of this city to enter upon the above-mentioned property forinmpcct!on purposes. Delo. Applicanl