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it LJOBADDRESS; PERMIT#: LICENSED CONTRACTORS DECLARA'T'ION I I hereby affimt that 1 am licensed under the provisions of Chapter 9(eomonencing with Section 7(XK)l nf'Divisian 3 of the Business and Professiant Cole. and my license is in full force and effect. License N Ex pate p.: Date __Cant:actor_ OWNER-BUILDER DECLARATION I herehy affirm[hal f am exempt from the Contractor's License Law for the fallowing reason(Sec.713 1.5.Business and Pmrassions Cndc: Any city or coua[y which requires a permit to construct,alter.improve.demolish,or repair any sinecure,prior to its issuance.alsn requires the applicant for such permit to file a signed statement that hit is licensed purvuam to the provisions of the Contractors License Law I Chapter 9{commencing with Section 7Wl)}of Division)of the business and Professions Code)or that he is exempt herefrnm and the basis for the alleged exemptioc. Any Violation of Section 7031.5 by any applicant for a permit sUbjccls ltie applicant to a Civil penalty of not more than fire hundred dollars(3501 q; I I ❑L 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 fur sate (Sec.7044,Business and Professions Cud;':the Contractor's License Law does not apply to an owner of property who builds of improves thereon,and who i I docs such work himself or through his own employees,provided that such improvements oveents arc not intended or offered for sale. If,however,the building or I improvement is sold within tire year or comp!ction.the owner•builder will have the burden of proving that he did not bdild or improve for the purpose of sa lc,) ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project ISec.7044,Business and Profession Code:The COntrOCWT'5 License Law does not Apply to an ow•ntr of property who builds or improves thereon,and who conimetx for such pro)etxs with a contmctor(s) licensed purse and to the Contractor's License Law-1 i ❑I am exempt under Sec. P.C.for this reason dale {)caner WORKERS'COMPENSATION DECLARATION 1 hereby affirm[hat I have A certificate of consent to self-insure,Or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.18N Iab.C). ' F.4p.Date Company 0 Certified copy is hereby famished D Certified copy is filed with the County Building Inspection Divisiu:t i CERTIFICATE OF FXF.MPTION FROM WORKKRS'COMPENSATION 1NSUR_4NCF. (This section need not be completed•if the permit is for one hundred dollars($1W)or Iess) I certify that in the performance of the work for which[his permit is issued.1 shall nor entploy any person in any manner.an as to became subject int hu Workers'Compensation Laws os'Catiromia. Dare Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should hecomic subject la the Wurktrs-Compensatinn prmisions of the Lahor Codc.you nits[forthwith cwmpiy with such provisions or this permit shall be detnted Tevuked. CONSTRUCTION LENDING AGENCY 1 herehy ntlirm that there is.1 construction Lending agency for the rfarmajim of the work for F Pe n r which this perrniris issued(sec.31197,Civ,C). Lender's Nanre L.endcr'r.Addm-s __ DIVISION OF INDUSTRIAL SAI"ry PF.RAIIT CERTIFICATION: 0 1 herehy certify that uu cxcuvatron five(,I)or more feel in depth into which a pc�, n is required to dtscend.will be make inconncctimt with work :wthari—I by the permit.and that no building structure,scaffolding,falsew—k,or demolition or dismantling thereof,will he Prom than thiny-six(36)feet high. (Chop.1.2,(trp 2.Art 2,Sec 341,Title 8,C.A.C.), ❑Ax uwner-huilder,I will not employ anyone to do work which would requi.c a Mme from the Division of fndvstrinl Sarcly,as notad above.unless such 's pension has a per mir lo do such work from the division, ❑Urrtsinn of industrial Permit Na. I mr[iry that 1 have read slits applicalron and smte that the above information is correct. (agree to comply with all city and county ordinances and state laws relating to well construerion and or sewage system construction,and hereby authorize representatives of this city to enter upon Lfse above-rmorini ed property I for inspection purpnscs, is Date. AppLicanl