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LICENSED CONTRACTORS DECLARATION I hereby at firm that I am licensed under the provisions of Chapter 9 commencing with Section 70001 of Division 3 of The Business and Pnrfession;Colic, ' and my license is to full force and effect. License H- _ Eap.:Date_. Date__Contractor_ t I OWNER-RCl HIER DECLARATION I 1 hereby ail nm that I am exempt from the Contractor's License Lav fix the following reason(Sete 7031.5.Business and Ptufessiuns Crain; Any city a' ' cuumv which reclaims it permN to construct,alter.improve,demolish.or, flair any structure.prior to r,issuance,also requires the Ipphem;L for such permit I hl file a signed statement that he is licensed pursuant to the provision,of the Contractor's License Law(Chapter 9(con•anrncing with Sectio:,71t(lo+of Division 3 of the Business and professions Codel or Thal he is cxempe hcrclrum and Elie basis for the alleged Cxemptien. Any v iolil of Stenon 70?1.9 hs Ucy applicant for a permit SubjcCu the applicant to a civil penalty of not nuvr than fire hundred dollars (550(b): O I,as owner of the property,or my employees with wages as their wlr eompenxmiun,will do the work.and the structure is not intended or ni fired Cor.air (Sec.7044.Business and Professions Cc(Ie:The Contractor s Liccn,:[.esu docs not apply to an owner of property who builds of improves therein,and w ho I docs such work itimsel(or through his awn employees,provided that rocs:intprnerments am not intended of offered for sale. It',however,the building or ' impnavenrent is sold within one year of completion,the owner-builder still have the burden lif proving that he did not build or improve for the purpose pr sale.) O L as owner of the property,am exclusively,cunnneting with licensed con:rmrore In construct the prujecs(Sec,7044.Business and Profession Codr:The ' C'ontractor's License U.CITIES not apply W an owner of property who builds or improves thereon,and who contracts fur such projects with a eontmeter(>) liCend pursuant to the Contractor's License Law.)— — ——-- — ❑1 in exempt under Sec. ,R S PC for llu.reason i Dare_ ' WORKERS'COMPENSATION DECLARATION { I hereby aff irm that I Kaye a certificate of consent to self-msurc,or a nTdir:ale of Workers'Compensation Insurance,or a ccrtficd rnrpy thereat tSce 3kttd, Lah.C'). ' Est, ll:dr-._.. -----Company- 0 _.__Company_0 Ccndied ropy is hereby furnished I 0 Certified copy is filed with the County Building Inspection Di,i,ion CERTIFICATE OF F.REMVI'ION FROM WORKERS'COMPENSATION INSURANCE � i t This seruon need nut be completed,if the permit is for one hundred dollars tS100)or less) ' i I cernfy that in the performance of the work for which this permit Is issue J.f shall not employ any person in any manner so x.t to become subject fur he Vii(kers'Compensation laws of Califilmia. i Date ..— _Applicant— -- --— -- --- — — ---- NOTICE TO APPLICANT:If.after making this Ccmfreaw of Fxenynion.you should become+ubied lir the Workers'Compensation provisions of th, Labor Code.you must forthwith comply wish such provisions or lhn permit shell he deemed revoked. I I CONSTRUCTION LENDING AGENCY 1 hcrcbv alfirm that There is a construction lending agency for the pent:r:r ante of the work for which this pernut is issued(Sec.3(197.Co.Ct. Lender's Name � Lender's Address_ I I DIVISION OF INIIUSTRI IL SAFETY PERMIT CERTIFICATION: O l hereby certify[hat no excavation five(5)or more feetin depth nuo rr hich a person is required In descend,will be make nr connection with work .ml6hui7ed by lbs permit,and Ihul no building srntrfure.sc.Rnhhag.�al.rwprk,or Janplition nr Aismunthng thereof,will be more Than shirty-six(36)I'cEt I 1 high. (Chap.3.2.Grp 2,Art 2,Sec 341,Title H.C.A.CJ. ' 0 As nx ncr-huifder,1 will not employ anyone io do work which would tegmrc a permit from the Dis jvun of Indusuial Safety,as coned above,unless such person has a permit in do such work from The division. i 0 Divrwn of InJu,En.d Pcrrmt\n._ I i I certify that l hat c lead this application and state that the above inktrnmtinn is correct. I agree to comply with all city and county ordinances and stale laws relating to well cnnslruction and ur sewage system construction.and hereby authonce representatives of Thu city in enter upon the shove-na:mionrJ property I lou inspection purposes. Date-- ._ _Applicant—