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JOB ADDRESS:
<br />PF,RMIT #:
<br />LICENSED CONTRACTORS DECLARATION
<br />1 hereby affimt that I am licensed under the provisions of Chapter 9 (commencing with Section 7(M)D) of Division 3 of the Business and Professions Code,
<br />and my license is in full force and effect.
<br />License N Exp.:
<br />Date Contractor
<br />OWNER -BUILDER DECLARATION
<br />I hertby affirm that f am exempt from the Contractor's License Law for the following reason (Sec. 7431.5, 13usine5s and Professions Code; Any city or
<br />county which requires a permit to construct, alter, improve, demolish, or rep it any structure, prior to its is.kiiance, :dao requires the applicant for such permit
<br />to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7004) of
<br />Division 3 of the Business and Professions Code.) or that he is exempt hcrtfrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br />any applicant for a permit subjects the aM)Iicant to a civil penalty of not more than five hundred dollars ($5(11))):
<br />❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not Intended or offered for sale
<br />(Sec. 7044, Business and Professions Code: Tlie Contractor's License Law does not apply to an owner of property who builds or improve, thereon. and who
<br />docs such work himself or through his own employees, provided that such improvernent, arc not intended or offered for sale. If, however, the building or
<br />improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of
<br />sale.)
<br />j ❑ [,as owner of the property, am exclusively contracting with licensed contractors to construct the project ISec. 7044, Business and Profession Code: The
<br />Contrnctcr's License Law does not apply to an owner of property who huilds or improves thereon, and who contracts for., uc h projects with a contracturfs,)
<br />licensed purxuant io die Contractor's License Law.) t r t
<br />❑ 1 am exempt under Sec
<br />Date _ _ Q% ner
<br />_, B & Y.C. fur thi$ reasort !
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insuntnc:e, or a certified copy thereof (Sec. 3800,
<br />I.ah. C).
<br />Exp. Date
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is filed with the County Building Inspection Division
<br />CERTIFICATE; OE'EXEIMPTION FROM WORKERS' U0.10MNSATION INS-L•'R.•liNCE
<br />(This section need not he completed, if [he permit is for one hundred dollars (5100) or less)
<br />I certify that in the performance of the work for which this permit is is_eued. I shall note niploy any person in any manner so as to becumc subject tot he
<br />Workers' Compensation Laws of Cahfurniu.
<br />Date_ . _ Applicant
<br />NOTICE TO APPLICANT: If, after nicking this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the
<br />Labor Code, you must forihwilh comply with such piovisions or this peririt shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCA'
<br />1 hereby affirm Ihm there is a construction ]ending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C).
<br />Lender's
<br />Lender's
<br />DIVISION OF INDUSTRIA 1. SAFETY PERMIT CERTIFICATION:
<br />❑ 1 hereby certify that no excavation five (5) or inure feet in depth into which a person is required to descend, will be make to connection with work
<br />authorized by the permit, and that no huilding structure., scaffolding, falscwork, or demolition or dismantling thereof, will be more than thirty-six (36i feet
<br />high. (Chap. 3?, Grp?., Art Sec 341. Title 8, C.A.C.).
<br />❑ As owner -builder, I will not employ anyone to do work which would require a permit from [lie Division of Industrial Safety, as noted above, unless such
<br />person h.is a permit to do such work from the division.
<br />O Division of Industrial Permit No.
<br />i certify that I have read this appitcation and stare that the above information is correct. ( agree ro comply with all city and county ordinances and state haws
<br />relating to well construction wid or sewage system construction, and hereby authorize representatives of this city to enter upon the above-mentioned property
<br />for inspection purposes:
<br />Date .. -_Applicant .
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