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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of chapter 9 fconanencing with Section 71100)of Division 3 of the Business and Professions Code, and my license is in full force and effect. License stExp.:Date Date Contractor OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's Licensc Law for the following reason(Sec.7031.5,Business and Professions Code;Any city or county which requires a permii to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit 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 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 permit subja is the applicant to a civil penalty of not more than five hundred dollars($50(y): ❑I,as,owner of the property,or my employees with wages as their sole compensation,w ill do the work,and thr.structure is not intended or offered for sale (Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who floes such work himself or through his own employees,provided that such tmproverrtcnts arc not intended or offered for We. If.however,the building or improvement is sold within one year of completion.the owner-buildor will have the burden of proving that he did not build or improve for the purpose of sale.) ❑L as owner of the propeny,am exclusively contracting with licensed conuacrors to construct the project(Sec_7044,Business and Profession Code:The Contractor's License few does not apply to an own.-r of property who builds or improves thereon,and who contracts for such projects with a connattor(s) licensed pursuant to the Contractor's License taw.) ❑1 am exempt under Sec.___ ,B R P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION 1 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. Lab.C), Exp.Date Company, _ II ❑Certified copy is hereby furnished ❑Certified copy is filed with the County Building Inspection Division JCERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed,if the permit is for one hundred dollars($100)or less) I certify that m the performance,of the work for which this permit is issued I shall not employ any person in any nsanner so as to become subject tot he 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 previsions 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 performmce of the work for which this peTmtt is issued(Sec.3097,Civ.Q. ' Lender's Name- Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION. 0 I hereby certify that no excavation five(5)or more feet in depth into which a person is requited to descend,will be make in connection with work authorized by the permit,and that no building structure,scaffolding,falwwork,or demolitinn or disman8ing thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Grp 2,Art 2,Ser 341.Title 8,C.A.C.). . ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Permit No. 1 certify that I have read this application and state that the about information is correct. 1 agar to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this city to enter upon the above•mentioned property for inspection purposes. Date__ Applicant