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JOB ADDRESS: PERMIT # LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under the previsions of Chapter 9 (cnmtrx:ncmg with Section 7000) of Division 3 of the Business and ProfCtisians Calc, and my license is in full force and effect. License # Exp.: OWNER -BUILDER DECLARA'T'ION 1 hereby affirm that I ant exempt fran the Contractor's License Law for the following reason (Sec. 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 tthc :y)plteaut for sura 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 7(00) of Division 3 of the Business and Professions Code) or that he is exempt hcrefrom 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 hundrrd dollars (S500)): 1, as owner of the property, or my employees with wages as thea sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon. and who docs such work himself or through his own employees, provided that such improvements are nor intended or offer«d, for sale. If, however, the building or improvement is said within one year of completion, the owncr-buikier will have the burden of proving that he did pal build or improve for the purpose of sale.) C1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 70.14, BusinCcs and Profession Cock:: The Contractor's License Law does not apply to an owner of property who builds or improves Thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law.) C] I am exempt under Srx. , B & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a ccrtificale of Workers' Compensation Insurance, or a certified earpy thereof (Sec, 3800, Lab. C). Exp. Date Company El Certified copy is hereby furnished ❑ Certified copy is fled with the County Btuldih%Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed, if the permit is for one hundred dollars ($100) or kss) 1 certify that in the perfonnance of the work for which this permit is issued. I shall not employ any person in any manner so as to become stthject to the Workers' Compensation Laws of California. Date NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workcrr,' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a c on{tructtdn lending agency for Ute performance of the work for which this permit is issued (Sec. 3()97, Civ. C). Lender's Name Lencicr'R Atkimss 4 ~ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 111 hereby cenify that no excavution five (5) or more feet in depth into which a person is required to descend, will be make in connection with work authorized by the permit, and that no building suhtcture, scaffolding, falscwork, or demftion or disminrling thereof, will be mon: than thirty-six (36) feet high. (Clhap. 3.2, Grp 2, Art 2, Sec 341, Title 8, C.A.C.). ❑ As owner -builder. I will not employ anyone, to do work which would require a permit from the Division of industrial Safety. as noted above, unless such person has a permit to do such work from the division. 13 Division of Industrial permit No. I certify that I twve read this application and state that the above informaiion is correct. 1 agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize reprscritWives of this county to enter ulwn the above-mentioned property for inspection purposes.