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�S ;��Jos ADDRESS: PERMT N•
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed tinder the provisions of Chapter 9(conmumcing with Section 7000)ofDivisiou 3 of the Business
<br /> and Professions
<br /> �Code
<br /> Gand my license is in full force and effect. �!
<br /> License k ! �'Z! r FigAr'atlnn Date
<br /> Date d Cooft& or &A-eyAp -4�L —6G 4, of-c<-, ,� 1*,e—
<br /> (wo 469C
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<br /> -—
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Cade: Any city or county which requires a permit to construct,alter,improve,dernolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of not more then five hundred dollars($500));
<br /> Q 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon,and who does such work himself or through his own employees,provided that swab
<br /> improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for the pvrpose of sale.)
<br /> i
<br /> D 1,as owner of the property,am exclusively contracting With licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to au owner of property who builds or improves bereon,
<br /> and who constructs for such projects with a contractors)licensed pursuant to the Contractor's License Law.)
<br /> O I am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'.COMPENSATION DECLARATION
<br /> I berehy affirm that I have a ccrtiiw*of consent to self-insure,or a cehtificate of Workers'Compensation Insurance,or a certified
<br /> copy thereof(Section 3840,Labor Code).
<br /> Expiration Date Company
<br /> O Certified copy is hereby furnished
<br /> O Certified copy is filed with the Environmental Healthy Department
<br /> I
<br /> CERTIFICATE OF EXEMPTION FROM WORKFRS'COMPENSATION INSURANCE
<br /> (MI section need not be eompletod if the pmmh is for QN hundred dollars($1001 or Lesal
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any masher so as to
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: I Applicant
<br /> NOTICE TO APPLICANT: IC after makiag this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you nnrst forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that theca is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code),
<br /> Lender's Name f ''
<br /> Lender'Address
<br /> DIVISION OF INDUSTPIAL SAFETY PERMIT CERTICATION
<br /> O 1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in
<br /> connection with work authorized by the permit,and that no bading structure,scaffolding,falsewadr.or demolition or dismantling
<br /> ihermf,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title ll,California Administrative
<br /> Code)-
<br /> E3 As owner-builder,I will not employ anyone to do wodr which aroWd require a permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> O Division of lndustdW Safety Permit#
<br /> I certify that I have read this application and state that the above information is correct.1 agree to comply with all city rind county
<br /> ordinances and state laws relating to well construction and or sewage system constructicA and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes
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<br /> Date Applicant.-
<br /> EHD 43-02-M MASTER Wa6a Weft Pamir Comwedw Deduactkm
<br /> 5482002
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