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JOB ADDRESS: PERMIT #:
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that I am licensed under the provisions of Clutpter 9 (commencing with Section 7000) of Division 3 of the Business and Pnrlessions Cnde,
<br />and my license is in full force and effect.
<br />License M
<br />Date Contractor
<br />Exp.:Datc
<br />OWNER -BUILDER DECLARATION
<br />1 hereby affirm that I am exempt from the Contractor's License Low for the following mason (Sec. 7031.5, Business and Professions Cude; Any city or
<br />county which requires a permit to construct, aher. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for sura permit
<br />to file a signed statement that he is licensed pursuant to the provisions of the l ontimclor's Uccnse Law (Chapter 9 (commencing with Section 7()n0) of
<br />Division 3 of the Business and Professions Code) or that he is exerttp( hcmfrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br />any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500)):
<br />❑ 1, as owner of the property, or my employees with wages as their sok compensation, will do rho work, and the smXturc is not intended or offered for sale
<br />(Sec. 7044, Business and Professions Code; The Contractor's License Law dors not apply to an owner of property who builds or improves thereon, and who
<br />does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or
<br />improvement is sold within one year of completion, the owncr•builde r will have the burden of proving (hat he did rxu build or improve for the purpose of
<br />sale.)
<br />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Profession Code, Tbc
<br />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 contractor(s)
<br />licensed pursuant to the Contractor's license Law.)
<br />❑ I am exempt under Sec. , B 8e P.C. for this Mason
<br />Date Owna
<br />WORKERS' COMPENSATION DECLARATION
<br />1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800.
<br />Lab. Q.
<br />Exp, Date Company
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is filed with the County Building Inspection Division
<br />CERTIFICATE OF EXENIPTION FROM WORKERS' COMPENSATION INSURANCL
<br />(This section need not be completed, if the permit is for one hundred dollars ($100) or less)
<br />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
<br />Workers' Compensation Laws of California.
<br />Date
<br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Computsation provisions of the
<br />Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3(197, Civ, Q.
<br />Lender's Nance
<br />Lender's
<br />DIVISION OF 1NDUSIRIALSAFE'1'YPERMIT CERTIFICATION:
<br />❑ 1 hcrrcby certify that rte excavation five (5) or more feet in depth into which a person is required to descend, will be make in connection with work
<br />authorized by the permit, and that no building structure, scaffolding, falscwork, or demolition or dismantling thereof, will be more than thirty-six (36) feet
<br />high. (Chap. 3.2, Grp 2, Art 2, Sec 341, Tile 8, C.A.C.).
<br />❑ 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
<br />person has a permit to do such work from the division,
<br />❑ Division of Industrial Permit No.
<br />I certify that 1 have read this application and state that the above information is cortcct. I agree to comply with all city and county ordinances and state laws
<br />relating to well construction and or sewage system construction, and hereby authorize representatives of this county to enter upon the above-mentioned
<br />property for inspection purposes.
<br />Date
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