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JOB ADDRESS: PERMIT Dl LICENSED CONTRACTORS DECLARATION I hereby off n that I am besnsed under the previsions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and professions Code, and my license is in full force and effect. Licensee Exp.:Dase Dale COOVIN or OWNER.BUD.DER DECLARATION I hereby affirm that I am exempt from the Contrmmt's license law for the following reason(Sec.7031.5,Business and professions Code: Any city m county which requires a panic to construct,alter,improve,demolish,or repair any structure,prior to its issuance-also requirrs the applinant for such permit m filea signal statement that he is licentad pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)Of Division 3 of the Business and Pmfessiom Cock)or that he is exempt herefrem and the beau for the alleged exemption. Any violation of genion 7031.5 by any applicant for a permit subjects We applicant to a civil penally of not more than five hundred dollars ($500)): I O L as owner of the propcny,m my employees with wages as their sole compensation,will do the work.and the naotere is not intended of offered fur sale (Sra.7D64,Business and Professions Code:The Commences License Law dues not apply ro an owns of property who builds as improves demon,and who does such work himself or through his own employee,provided that such impcovemeots one not intended or offered for sale. If,however,the building os improvement is sold within one year of vem(letim,the ewacr-builder will have the burden of pmvmg that he did nor build or improve for The purpose of sale.) ❑L as owner of the vapory,can exclusively cuntrudng with licensed conuacton to construct the project(See.7044.Business and profession Code:The Comeector's License law does not apply in an owner of property who builds or Improver therwn,and who contacts for such projects with a conseeter(s) licensed pis meant to she Contractor's License law.) ❑I am exempt under Sce. B R p.C.fm this roasen Duro pwrcr WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of content in sill-Insure,no a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800. Lab.C). Esp.Dale Company ❑CMifled copy is bereby famished ❑Certified copy is BIM with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This secdon need net M completed,if the permit is for one hundred dollars(S 100)or las) 1 seWily that in the or ce of she work for which this pennon is issued,)shall nemploy any person in any manner so ss so beco e pame subject ren he Workers'Compassstinn Laws Of Califenia Dose Applicaru you should become auhjeet to the Workers'Compenaxdon provisions of de NOTICE TO APPLICANT:b after making this pum,m ns of Exemption., Labor Cede.You..at forthwith comply with such provisions err tM1is permit shall be dmmrd rooked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for she performance of the wmk for which this permit is Issued(Sm-3077,Civ,Q. Lender's No Lender's Address _I u'VISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O I lscrehy¢rt.fy dim m ex:avvtion five($)m mem feet err depth intra which a person is required to descent.Will be make in connection with work author rad by the pmriq nnt char w hu0ding arrucsutt,scaffolding,hh-amok.or demolition or dismantling thenen[,will be-come dun ibirty-tis(36)fear high.(Clop.3.2,Grp 2,An 2,Sec 341,Title S.C.A.C.) O As owner-builder 1 will not employ anyone to do work which would mquiu a permit from the[Nvisim,of Industrial Safety,os noted above,unions wch person her a permit to do such week from the division. O Division of Industrial Femit No. I certify ohm I have read this spplicatiOn and stafc that the above infarmmion is correct I agree to comply with all city and county adinseces and see laws Mating to+elf consrmetio,and or sewage system construction.and hereby outhodu mpreuntativea of this city to caner upon the above-niendnned pe-Pcny fee inspection purposes. .Dario Applicant