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Joi ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I heteby affirm that I am licensed under the provisions of Chapter 9(cornmencing with Section 7000)of Division 3 of the B minw and Professions Code and ray license is in full force and effect, License# Expiration Date Date Contractor s•� OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Code. Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement dw he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and iProfkasians Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofnot more than five hundred dollars(5500)): ❑1,es owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not invaded or offered for ask(Sectiat 7044, Business and Profemions Code:The contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,howevta,the Wilding or improvement is sold within one yea of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) O 1, as owner of the property,am exclusively contracting with licensed contractors to construct the projoot(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)licensee:pursuant to the Contractor's License Law.) ❑1 am exempt under Section B"C for this mason_ Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of W orkcr3'Compensatinst lnatuanas,or a certified copy thereof(Section 3600•Labor Code)_ Expiration Date Company ❑Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE aha se- on tread sot be conVIe ed if 4r,y9Z is far ams Indred do fS 100)or kssl I certify that in the performance of the work for which this permit is issued.I shall not employ any pawn in say mantras so as to become,object to the Wortsrs' Compensation taws of California. Date: Applicant NOTICE TO APPLICANT: If, after snaking this Certificate of Exemption,you should become subject to the Workers' Compensation provisions of the Labor Code,you must forthwith comply with sucb provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the perf of the work for which this permit is issued(Section 3097,Civil Code)_ 4.t*4kr s Name Lender'Address See. C&Je. S� b� 3q 3