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JOB ADDRESS: PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,
<br /> and tity license is in full force and effect.
<br /> License# Exp.:Datc
<br /> Date Contractor
<br /> -- _ -- -- _� - .�.�•,,—. ...�..- �,,,•�-- ; OWNER-IIUILDEIi DECLARATION '
<br /> ems. �.- . ...
<br /> I hereby affirm that I am exempt from the Contractor's'Licc rise Law for the following reason(Sec.7031.5,Business and Professions Code; Any city or
<br /> county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
<br /> to 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
<br /> Division 3 of the Business and Professions Code)or that he is exempt hercfrom and the basis for the alleged exemption. Any violation of Section 703 L5 by
<br /> any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)):
<br /> ❑1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure isnot intended or offered for sale
<br /> (Sec.7044,Business and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who
<br /> does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,however,the building or
<br /> improvement 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 of
<br /> sale,
<br /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7014,Business and profession Code:The
<br /> Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractors)
<br /> licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Sec, B&P.C.for this reason
<br /> Date Owner
<br /> I 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 copy thereof{Sec.3800,
<br /> Lab.Q. .
<br /> Exp.Dat-c Company
<br /> ❑Certified copy is hereby furnished
<br /> 13 Certified copy is filed with lite County Building Inspection Division
<br /> CERTIFICATEOF EXEMPTION FROM WORKERS'COMPENSATION INSURANCL
<br /> (This section ticed not be completed,if the permit is for one hundred dollars($100)or less) !
<br /> certify that in the-performance ofthe-workforwhich-this-permirPstssued-I-sh' iioC e' Ivy any personin airy manner so as to becntnc suhjccl to the
<br /> Workers'Compensation Laws of California.
<br /> Date Applicant f
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yo should become subject to the Workers'Compensation provisions of the
<br /> Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked,
<br /> 1
<br /> CONSTRUCTION LENDING-AGENCY.
<br /> i .
<br /> I hereby affirm that there is a construction]ending,agency for the performance of the,work for which this perm t is issued(Sec.3097,Civ.Q.
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> ❑I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will 6e make in connection with work
<br /> authorized by Clic permit,acid that no building structure,scaffolding,falsework,or dcmofition or dismantling thereof,will be more than shirtytsix(3G)lett
<br /> high. (Chap,3.2,Grp 2,Art 2,Sec 341,Title 8,C-A.C.).
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of fndustrial Safety,as noted above,unless such
<br /> person has a permit to do'such work from the division.
<br /> ❑Division of Industrial Permit No.
<br /> 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 ordinances and start laws
<br /> ncd
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the ordinances
<br /> c s and i arc
<br /> property for inspection purposes. '
<br /> Date ° x
<br /> . ------Applicant .. .. �.
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