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Jot ADDRESS: PERNUT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)ofDivision 3 of the Business and Professions Code and ray license is in full force and effect, License# Expiration Date Date Contrsetor s� � � OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and PtofesMons Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requirrs the applicant for such permit to file a trigned statern em 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 Business and iProfeuiew 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 of not snore than five hundred dollars(5500)): 13 1,as owner of the property,or my employees with wags as their sole compensation,will do the work,and the snvcture is riot intended or offered for sale(Section 7044, Business and Professions Code:The contractor's License Law does not apply to an owner of property who builds or improves dxxem,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,howev:.-r,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) 111, as owner of the property, am exclusively contracting with licensed contractors 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)licensee;pursuant to the Contractor's License Law.) ❑1 am exempt under Section B&PC for this mason_ Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affrrm that I have a certificate of consent to self insure,or a certificate of Workers'Compensation Insurance,or a certified copy tb reof(Section 3800,Labor Codc)- Expiration Date Company ❑Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Cais section stood nut be completed ifthr U3A is forme hundred dollars(S 100)or kss) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Workua' Campernsstion Laws of caJifomia. Date: Applicant NOTICE TO APPLICANT: If, after snaking this Certificate of Exemption,you should become subject to the Wor'sers' 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 constntction hording agency for the performae of the work forwhicb this permit is issued(Section 31197,Civil Code). 4.**d4r s Name Lender'Address See. a6eve.