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gob ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect License# Expiration Date Date Contractor s AC.0" 1 OWNER-BUILDER DECLARATION I hereby affirm that l am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Code: Any city cr 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 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the BLminess and Professions Code) or that he is exempt lwmfrom 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 of not more than five hundred dollars(S500)): O 1,as owner of the property,or ivy employees with wages as their sole compensation,will do the work,and the structure is not imended or offered for sak(Sown 7044, Business and Professions Code:The contractor's License Luw does not apply to an owner of property who buildr.or improves thereon,and who does such work himself or Through his own employees,provided that such unprovemene ate not intended or offered for sale. if,however,the building or improvement is sold within one year of completion,the owner-builder will have the hurden of proving that he did not build or improve for the purpose of sale.) D I, as owner of the property, am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Cotte (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.) 0 I am exempt under Section B&PC for this reason_ Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a ccstificate of Workers'Compensation Insurance,or a certified oopy thereof(Section 3800,Labor Cade) Expiration Date Company ❑Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Mis section need not bs M=leted if the uermit is for one hundred dollars(S 100)or less) 1 certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become aubject to the Workera' Compensation Laws of Califomia. 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 perforna�ofthe work for which this permit is issued(Section 3097,Civil Code). Q- feende Name FF D�,r � .•�-F L..P. Lender'Address $ee. CtbfJe.