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SOB ADDRESS: PERMIT k: LICENSED CONTRACTORS DECLARATION 1 hereby eff:rm that f am licensed under the providons of Chwt.9 tcom—ming with Section 70110)afDivision 3 of the Business and Pmf srsions Ced4 and my license is in full font and effect. License a_ _Exp:Dwe Dore Cartmcnr, n • OWNER-BUILDER DECLARATION Ihxby aRrm thmlam eaemlA from the Convactm's Lcense Law fm the folbwing rnson(Sec.7031.5.Busineaa and Profcssiens Cade: Anycityor county which requires a permit to construct,alter.imptoye.i mdish..mpmr any structure,prior to its issuance also maim the applicant fa such permit to fife a signed suamcm that M is licensed pursuant Indic provisions arthc Contra.or a License Law(CTaptar 9(cat arrica mg with Section 7001 Drvi,km3ofda,Businc.and Rn[usioos Cade]or that he uesempt hrrefmman6 Ne basin for the alleged eaempim. Anymbanamof Sectinn71131.5by any applicant for a Permit subjects the apPlicam to a owil penally of nm mart than five hundred&]him(S5(m)): ❑I.as owns of the Property,or my emplayees with wages as their side compensation,will do the work.and the xttuctwe is .at Imcrded err offered for sok (Sec.700a,Basic.and Prefession,Cade:'Ma Coavactar's Liceme law dues as apply an en owner of property who builds or impm is,thereon,and wfm does matt work himself or through his awn employed,provided thin such improvememc are trot imende6araDertd for sale If,however,the building or r improvement asold within one year ofcompletioe.the owner-builder will hme the burden of proving that hedid am build or improve for pmWsc of selc.) O I,as owner of the Property.am exclusively contracting with licensed rnmuselass to construct the project(Sec.70",Business and Profession Code:The Cmuract is License Law does not apply in an owner of property who builds or impmn.thereon,and who cantmctv far such projects with u convsmts) licensed pursuant m ilia Conhacmr's License Law.) - i Olamexempt undo Sa. HkP.C.fomhis reamv � Dater Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that 1 love.ecnificse of consent: o.114....or a.enifok of Workers'Compevavau I..,err a certified ropy nercor(Nee.3904 Lab.C) Exp.Date Company I ❑C<dilled copy is herby furnished ❑C rdricd copy is filed with the County Building Inspection Divi son CERTIFICATE OF EXEMPTION FROM WORKERS'COM PF,NSATION INSURANCE - (%a saliou nad rpt be completed,if the permit is far oro haMted dd n,,(SI Off or least 1 ceNry that in the performmh¢of the work for which this permit is Issued.)shell not employ any person in any manner to as 1.become subject ha he 11 Workers CmaPensWiov laws of California. Date Applidnl NOTICE TO APPLICANT:If,alta tusking this Certificate of F.semptaa yrou should become subject to the Webers'Coupematfon provispns of 1M LaborCode.you mus fnnhwithcomply with such pmsssions err Nis psvntil shallhadeemerl revoked. CONSTRUCTION LENDING AGENCY 1 hatch,aff nth tins there is a eonstrue6an lending agency forthe perfornoccc a da work for which this p.udh is issued(Sec.3097,Civ.C). IeMer's Name Lenders Aedms DIVISION OF INDUSTRM 1.SAFETY PERMIT CERTIFICATION: ❑I heraby certify thin an excavation five(5)m marc feet in depth into which a person is required to dexerd.unit be,make in connection with work amhndyed by da permit,a al thin ho building measure,sesRokling.faiscwurk,as demolitan m dismantling thereof.will be mere than thirty-six(36)fm high. (Chap.3:2,Cup 2,Aa2.Sm3al.Tille 3.CACI. ❑As own.builder-I will oat employ anyone-do wok width-add r.quire a p.mn fmsn dtc D.i,nou of Industrial Stif ey.as total ahmve•unless such Peaspn has a p.rrdt to doauch work fmm the divaion. ❑Uivisian of Industrial Forms No. I ' I cmlify Nat I have and this application and situ that This above itineration is comet. 1 agree to comply with all city and county cadimmss and use laws raising to—11 construction and or sewage ssi comvumian and Ipreby analami.rep assertive.of this ity to enteopon fl.abaft-onectim ed pmpeny, far hupennn puryosca. Dmc- Applicav_-_ _ J