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�I JOB ADDRESS: PERMIT M: LICENSED CONTRACTORS DECLARATION I herebyall*'(m that 1 am hccnsed under the pruvtstuns of Chapter')(commencing with Section 7000)of Division i of the Business and Pro(essions Code. and miv Ilecnac s in full force and cheer. License a - Exp.:Da(c_— -- Date Conaac(or iOWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Sec.7031.5.Business and Professions Code: Any city or comuy which rrquires a permit ro construct.alter,improve,demolish,or repair any strucsuc,prior to its tauance,also requires the applicant for such permit to file a signed ctatetnem th;ir he is licensed pursuant to the provisions of the Comracmr's(.Xenia Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Prnfessiuns Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.3 by 't any applicant fon a permit sub(ectS use applicant to a civil penalty of not more than five hundred dollars (SS0(ljl. I Q 1,as owner of the prcgocny,or my rn�oloyccs with wages is their sole camKnsahun,will do the work,and the struaurr rs nut uirendcd or offered far sale (Sec.7(M4.Business and Professions Code:rhe Contractor's T.icense IAw does nor apply ni on ownerof property who hudds or improves thereon,and who does such work himself or through his own employees,provided(hai such improvements are rat intended or offered for sale If,lx)wcvcr,the building or improtemrni is sold wnhin one year of comfietion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.I ❑1,as owner Of the propcm,,am exclusively comraciing with licensed contracton to construct the project(Sec.7044.Business and profession Code: (he %1 Connactox's License Law does not apply to au owner of pruperty who builds or improves thereon,and who contracts for such projects with a coniracinns) t licensed pursuant to the Contractor's License Law.) ❑1 am exempt under Sec B A P.C.far this mason I) (0vnrr WORKERS'COMPENSATION DECLARATION I f I hrrrlqaffirm that 1 have a cerificate of consent to self-insure,or a cartsGrate of Wlxkers'Compensation Insurance,or a eenifted copy thereof(Sec.1g00, Loh.C). i Exp Datc _Company _ _-- -- ❑CerliGed copy a hereby furnished J✓ ❑Certified copy is filed with the County Building Inspection Division j t CERTIFICATE OF EXFMPTION FROM WORKERS'CCIMPF.NSATION INSURANCE 1 ` (This section need nor he completed rt the permit is farrier:hrndred dollars 15100)arless) I i 1 certify that in the per(oi mance of the wodc fur which this p,;rmi(is issued.I shall not einpley any pemon in any manner sea m to become subject ort he Workers'Compensation laws of Califnmiu. Date_- _ —Applicant— _ _ — — —— --- ——— —_ NOTICE TO APPLICANT:If,after making this Certificam of Exemption,you should Become o subject to the Workers'Compensation provisions of the I T 1 ibor Codc,you must forthwith Comply with Au&provisions or this permit shall he dcemod revoked. CONSI RUC11ON LENDING AGENCY I herehv affirm that there is a construction lending agency for the performance of the work for which thin permit is issued(Sec 3097,Civ.C). I ' Letntcr's Name_. Lender's Address_ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: Q r hereby certify that no exravatiun five(5i or nustr feet in deprh irm which a person is required to descend,will be mark(in conneerinn with work authorized by the permit,and that no budding structure,scaffolding,fduwork.or demolition or dismantling thereof.will lie nxire than rhiny-six(36)feet Mgt, i Chap.7.?,rep 2.tin 2.Sec 341,Tide P,C A C.1. ❑As owner builder,f will own employ anyone to du svaxk which would require,a permit from the Division of lndminat Safety,■s noted ahove,unless such person has a permit!o do such work from the division. ( rhvvucin u Nin.D f Jnaumnal Permit _. I crud)that I ha•e read this application and sate that the above information is correct. I a$tTC lea comply with all tit)and county ordinances and state laws relating w w ell cansuuc(inn and or sewage system consinic(ion-and herebv authorize representatives of this city to enter upon the above-mentioned proper) fonnspec'inn purposes Date— — —Applicant! ----