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709 AD9R955: O'"4 101 /G�t rxed✓ PERMIT#: LICENSED CONTRACTORS DECLARATION �� I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division IC and Professions Code and my license is in full force and effect. f� Lleense# 7�Wy '�B Expiration Date Date Ic Contractor AZE>r grwfl— ; ora OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Comracmr's License Law for the following mason (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct,altet,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit W 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 pemdt subjects the applicant to a civil penalty of not more than five hundred dollars($500)): 13 I, as owner of the property,or my employees with wages as thew sole compensation,will do the work, and the structure is not intended or offered for sale(Section 7044,Business and Professions Code:1160 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 own employees,provided that such improv0mrnts are not intended or offered for sale. If,however,the building or in provement is sold within one year of completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose ofsale.) ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a cmuractor(s)licensed po soam to the Contractor's License Law.) ❑1 am exempt under Section B&PC for this reason Dale: 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(Section 3800,Labor Code). Expiration Date Company _ ❑Certified copy is hereby furnished O Certified copy is filed with the Environmental Health DeWimeut CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This Section need not be comp) ted ifthe permit is for One hundred d llarc-(g 00 or—1051 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 to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' 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 lending agency for the performance of the work for which this permit is issued(Section 3097,Civil Code), Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION C1 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 connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be mom than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Administrative Cade). O As owner-balder,I will not employ anyone to do work which would require a permit from the Division of Industrie!Safety,as noted above,unless such person has a permit to do suet ivision. ❑Division mflndustrial Safety Permit# I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordimances and state laws relating to well ConsWetion and or sewage system construction,and hereby authorize representatives of this cowry to enter upon the above-mentioned property for inspection purposes. Date Applicant fil)43 2 erm43AS-0p7 5n MASTER Water Well Pit Coontin Dedaracti.