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PERMIT#: JOB ADDRESS; LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 70001 of Division 3 of the Business and lProfessions Code and my license Is in full force and effect OZ '7 3 7?3 9- Expiration Date License#U Date U 1 tf t0 Contractor�'S`� "2+ v S• OWNER-BUILDER DECLARATION -Om the Contractoi's n 7031-5, and I hereby affirm that I am exempt ctr requires a Permit o Lconsinrct,atticense Lawer,improve,the dnemolliishh..or repair anrstiv&ure P�r to its-issuance, Code: Any city or county also requires the applicant for such perma to file a signed statement that he is Licensed pursuant to the provisions of the Contractors s exempt License Law(Chapter 9(commencing with Sect on 7000)of Division 3 of the Business Y nit P�rofewons nt for a gCemtrt)subJteLt tithe applicant herefrom and the basis for the alleged exemption. Any violation of Section 7031,5 b an app to a Civil penalty of not more than fie hundred dollars($500)): ❑1,as owner of the property, or my empioyees with wages as their sole compensation.will do the work and the structure is not irftrided or offered for sale(Section 7044, Business and Professions Code:The contractor's License Law does not apVY to that yfI owner of property who builds or improves thereon,and who does such worts himself or through his own employees.provided such improvememis are not intended or offered for sale. If, however, the building or improvement is so within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpo ) Q 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(BBPC)- The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractors)licensed pursuant to the Contractor's License Law. Q I am exempt under Section B&PC for this reason Date: p r p y /o Owner. WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance certtfied copy thereof(Section 3800,Labor Code). Expiration Date Company _ ❑Certified Copy is hereby furnished I! ❑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 for one hundred dollars 1$100)or less) 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 become suNect to the 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 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 tending 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 ❑ I hereby oertify 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 permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof.will be more than thirty-six(36)feet high (Chapter 3.2. Group 2,ArtiGe 2, Section 341,Title B. California Administrative Code). ❑As owner-builder,I wil!not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted i V I above,unless such person has a permit to do such work from the division ❑Division of Industrial Safety Permit# I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county i ordinances and stale laws relating to well Construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspecton purposes Date Applicant /7') tiC[N::ED CONTRACTOR OECL4Rw7'!ON Ebro x3-07 �✓ t0l5107