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�nJ � � �JOB ADDRESS: !�
<br /> PERMrr k:
<br /> LICENSED CONTRACTORS DECLARATION I
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<br /> 1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License# 1-3- l; I A? Expiration Date 7r✓^W
<br /> Date Contractor e ,�►,s� ��� ��
<br /> OWNER-B 'ILDF.R DECLARATION
<br /> I hereby affirm that i am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and die basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty cf not more than five hundred dollars(5500)):
<br /> ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work,and the structure is not
<br /> intended or offered fur sale(Sectior:7044,Business and Professions Codi The contractor's License Law does not apply to an owner
<br /> of property who builds or improves hereon, and who docs such work himself or through his own employees, provided that such
<br /> improvements are not intended or offered for sale. If,however,the building or improvement is sold within one year of completion,
<br /> the owner-builder will have the burden of proving that he did not build or improve for Elie purpose of saic.)
<br /> ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&-PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,
<br /> and who constructs for such projects with a contractors)licensed pursuant to the Conaactor's License Law.)
<br /> ❑I am exempt under Section , B&PC for this reason
<br /> Date- Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that 1 have a certificate of consent to self-insure,ora certificate of Workers'Compensation Insurance,ora certified
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company _
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health Depan neot
<br /> CFRTIFTCATF OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This sections nerd not be completed if the permit is for one hundred dollars($100)or less
<br /> 1 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
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, after nicking this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code),
<br /> Lender's Name
<br /> Lender'Address
<br /> DMSION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ I hereby certify that no excavation five(5) or more feet in depth into which a person is required to descend, will be made in
<br /> connection with work authorized by the permit,and that no building structure,scaffolding, falsework,or demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feet high.(Chapter 3.2, Group 2,Article 2,Section 341,Title 8,Cakfo.nia Administrative
<br /> Code).
<br /> ❑As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit p
<br /> T certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 MASTER Water Well Permit Contractor Daclaraenon
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