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40B ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm thv I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Bwiness and Professions Code and my lice ase is in full force and effccL License# Expiration Date Date Contractor JLi OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 703 t.5,Business aria(Professions Cade: Any city or canny which j requires a permit to construct,alter,improve,demolish,or repair any Anicture,prior to its issuance,also requires the applicatit for succi permit to file a sued stawment that he is licensed putsuatit to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Bsninea and Professions Code) or that he is exerW herefrom and the basis for the alleged exemption. Any violation of Section 7031-5 by any applicant for a permit subjects the appliwtt to a civil penalty of not mote than five hundred dollen($500)): D 1,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 fir sale(Section 7041, Business and Professions Code:The contractors License Lair does not apply to an owner of property who buikU or improves thereon,and who does such wort bane)(or through his own employees,provided that such improvemene aro not intended or offered for sale. If,however,the building or improvement is sold within one year of completion,the owner-builder win have the burden of proving that he did not build or improve for the purpose of sale.) D 1,as owner of the property, am exclusively contracting with licensed contactors to construct the project(Section 7044,Business and Professions Code (B&PC): 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 contractor(s)licensed pursuant to the Contractor's License Law.) ❑I am exempt under Section B&PC for this reason_ I II Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a cestificate of wok=s,Cooipensat sm Insurance,or a certified copy thereof(Section 38ot1,labor Expiration Date Company ❑Certified copy is hereby furnished O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rMs section need not bs corny) if [ +t is icx otic htmdtffi dolharu(S 100)or lei] I certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manna so as to become aubjact to the Wakes' 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 lending agency for the pert ofthe work for which this permit is issued(Section 3097,Civil Code). s Name Lender'Address Sez, &6,je.