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<br /> JOB ADDRESS: PERMIT N:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affi,m that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Prufewions Code,
<br /> and my license is in full force and effect.
<br /> License M Exp.:Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.7031,5,Business and P.ofessions Code; Any city or
<br /> county which requires a permii to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
<br /> to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br /> any applicant for a pernut subjects the applicant Ica civil penalty of not more than five hundred dollars($500)):
<br /> O I,as owner of the property,or my employms with wages as their sole compensation,will do the work,and the.structure is na intended or offered for sale
<br /> ' (Sec.7444,Business and Professions Cock:The Contractor's License Law does not apply to an owner of pw-"y who builds or improves thereon,and who
<br /> does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,however,the buiiding or
<br /> improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve 1'or the purpose of
<br /> sale.)
<br /> Q 1,as owner of the property,am exclusively commuting with licerucd contractors to construct the project(Sec.10U,Business and Profession Code:The
<br /> Contractor's License Law does not apply to an own.:r of property who builds or improves thereon,and who connects for such projects with a contractor(s)
<br /> licensed pursuant to the Convactor's License Law.)
<br /> 111 am exempt under Sec. B&P.C.for this reason
<br /> Date V Owns
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,
<br /> Lab.Q.
<br /> Exp.Date Company— _
<br /> ❑Certified copy is hereby furnished
<br /> O Certified copy is filed with the County Building Inspection Division
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (,nis section need not be completed,if the permit is for one hundred dollars($100)or Ins)
<br /> I certify that in the performance of the work for which this p:nmit is issued,I shall not empioy any person in any manner so as to become subject tot he
<br /> 1 Workers'Compensation Laws of California.
<br /> Date Applicant
<br /> NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the
<br /> Labor Code,you most forthwith comply with such provisions or this permit shall be deemed revoked. ,
<br /> CONSTRUCTION LENDING AGENCY h
<br /> I hereby affirm dial there is a construction fending agency for the performance of the work for which this pmlrat is issued(See.3097,Civ.Q.
<br /> Lender's Name
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION.
<br /> ❑1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in connection with wmk
<br /> authorized by the permit,and that no building structure,scaffolding,fakework,nr demolition or disnAniing thereof,will be more than thirty-six(36)feel
<br /> high. (CTap.3.2,Grp 2.fn 2,Sec 341-'Pit1e 8,CA.C.)_
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safecy,as noted above,unless snrch
<br /> person has a permit to do such work from the division. I
<br /> ❑Division of Industrial Permit No.
<br /> i
<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 county ordiw�ces and state laws
<br /> relating to well construction and or sewage system construction,and hereby authorize repr-n latives of this city to enter upon the above•mzntioned property
<br /> for inspection purposes.
<br /> Date__ Applicam
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