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JOB ADDRESS: J azo ul E�aj dpi & d Pex6fff#t
<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 ofthe Business
<br /> and Professionps;Code and tmyy license is in full force and effect.
<br /> Llfsense# -71 L /�o
<br /> ( - Dir tla Date
<br /> Date -OZ, Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a pemdt to construct,alter,improve,demolish,or repair any structure,prior to
<br /> i 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 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 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 such
<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 purpose of sale.)
<br /> ❑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 an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> D I am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS'COMPFNSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insum.or a certificate of Workers'Compensation lamattce,or as cce`rttiftod
<br /> copy thereof(Section 3800,Labor Code). /I
<br /> f Expiration Date Company_S/,NJ,/�J U 'L /✓`^•--'I\.-C�. 'e.ris'`r'`''vv"'—�Uh
<br /> E3 Certified copy is hereby furnished
<br /> )gCertified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100)orless)
<br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to
<br /> become subject to the Workers'Compensation Laws of Califomfa.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with sucfproviisions or this permit shall bye deemed revoked
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a constriction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address -
<br /> DIVISION OF INDUSTRIA[.SAFETY PERMIT CERTICATION
<br /> i1 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 building structure,scaffolding,felsework,or dernoliion or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title S,California Administrative
<br /> Code).
<br /> ❑As owner-builder,I will not employ anyone to do work which would 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 Industrial Safety Permit# -_
<br /> I certify that I have read this application and state that the above information is correct.I agree to comply with all city and comfy
<br /> ordinances and sate laws relating to well construction and in sewage system co coon,and hereby authoprcaemratives of this
<br /> county m enter upon abbolve-mentioned property for inspection purposes.
<br /> Date '( / —� Applicant
<br /> EHD 43-02-007 MASTER Water Well Penmt Cmvacnor Decla tan
<br /> 52ar1002
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