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JOEL At)DRESS: --- - --- - — PERMIT#: - --
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 0 (commencing with Section 7000) of Division 3 of the Business and
<br /> Professions Code and my license is in full force and effect.
<br /> License # Expiration Date -__.
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's Licenso Law for the following reason (Section 7031.5, Business and Professions
<br /> Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance,
<br /> also requires the applicant for such permit to file it signed statement that Ile is licensed pursuant lu the provisions of the Contractor's
<br /> License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than five hundred dollars ($500)):
<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 for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an
<br /> owner of properly who bUIIdS or improves thereon, and who does such work himself or through his own employees, provided that
<br /> such improvements are not intended or offered for sal(,. If, however, the building or improvement is sold within one your of
<br /> completion, the ownor-builder will have the burden of proving that he cid not build or,improve for the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br /> Professions Code (BBPC): The Contractor's License Law does nut apply to an owner of property who builds or improves horeon,
<br /> and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's license Law.)
<br /> ❑ 1 am exempt under Section _ , B&PC for this reason
<br /> Date: - - -- - _ Owner- - ----- --
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' Compensation Insurance, or a certified copy
<br /> thereof (Section 3800, labor Code).
<br /> Expiration Date----- -------- Company---- - - ------ ------ ---- ---
<br /> ❑Cerlified copy is hereby furnished
<br /> ❑ Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($100) or Ices
<br /> I ceilify 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
<br /> pplicant------ ----- _ _
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br /> provisions of the Labor Code, you must forthwith comply will,such provisions of this permit shall be doomed 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 3097,
<br /> Civil Code).
<br /> Lender's Name -- ---- - - --- -- - - ---- -
<br /> Lender's Address-----,---
<br /> DIVISION
<br /> ddress-----._ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ►I ri I hereby certify Mat no excavation five (5) or more teat in depth into which a person is required to descend, will be rnade in
<br /> connection with work authorized by the permit, orad Ilial nc, building structure, Cca!1010119. falsowork, or demolition or dismantling
<br /> Ihereof, will hi .none than Thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Seclion 3,11, Title 8, Califowia Administrative
<br /> ❑ As owner-builder, 1 will not employ anyone to rin work which would require a permit frons the Division of Industrial Safely, as noted
<br /> above, unless such person has a permit to do such work from Iho division.
<br /> ❑ Division of Industrial Safely Permit it
<br /> I certify that I have read this application and state that the above information is correct. I 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 4302-007 LICENSED CONTRACTOnS DECI AnAI ION
<br /> 6 26 09
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