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air PERMIT J�RESS: LICENSED CONTRACTORS DECLARATION i 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 and ddymy License is in fu!t force and effect Licenser G � Expiration Date p( ./�d��Y Date _0 Contractor E<T�}, aF""'�< � 3 OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law far the follovwng reason(Section 7031 5 Business and Professions , m Ode Any city or county which requires a per !!tc construct oiler improve,demolish,or repair any structure,prior!o its issuance, also requires the applicant for such permit to fie a signed statement that he is Itcersed pursuant to the provisions of the Convactor's License Law(Chapter 9(commencing with Section 7000)Of Division 3 Of the Business and Professions Code)Of!hat he is exempt herefrom and the basis for the alleged exemption Any violation of Sedlon 7931 5 by any appl�r„ant foi a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)) 0 I,as owner of the property, or my employees with wages as their sole compensation. will do the work and the structure is not intended or offered for safe(Section 7044, Business and Professions Code fhe e01`1118000 License Law does not apply to an owner of property who builds or improves(hereon and who does such worx himself or through his own employees, provided that such improvements are not intended or offered for safe If, however the OLWding or improvement isPursolo pose of one year of completion,the ownef-builder will have the burden of proving that he did not build Vr�r71prove.for th@ 0 1,as owner of the pfoperty,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC) The Contractor's License Law does no,apply to an owner of progeny who builds cr improves hereon, and who constructs for such protects with a conlfactor(s)ficensed pursuanl to the COntrarior's License Law! C31 am exempt under Section B&PC for this reason —.— Date: Owner: 1 WORKERS'COMPENSATION DECLARATION I i hereby dfrm that I have a certificate of consent to Belt•insure or a cerifirrate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800.Labor lode) Expiration Date Company 0 Certified copy is hereby furnished O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is lot one hundred dottars($t00)or less) I certify that in the performance of the work for which this permit is issued.t shalt not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California Date: Applicant _,___._.----- -- NOTICE TO APPLICANT It, after making this Certificate of Exemption. you should become subject to the Workers'Compensation provisions 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 performance Of the work for which this permit is Issued (Section 3097.Civil Code) Lender's Name Lender'Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 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 connection with work authorized by the perms, and that no budding structurescaffolding, tatseworkor demolition or dismantling thereof,wilt be more then thirty-six(351 feel high (Chapter 3 7,Group 2 Article 2. Section 341. Title 8 California Administrative _ Code) 0 As owner-budder !will not employ anyone to do worn whiC;h would require a Derm4 from the Division or industrial Salety,as noted above,unless such person has a permit to do such work from the dwision 0 Division of Industrial Safety Permit# —------.�_ I certify that I have read this application and state that the above mlormatron is correct I agree to comply with all city and county ordinances and state laws relating to weft construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property rot tn$rectror~purposes Date Applicant L;CENSER COWRACIOR DECLARATION E!W 43-07