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JOB ADDRESS: PF•RMIT#' l , LICENSED CONTRACTORS DECLARATION ' I hereby effirrn that I analicensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Buskiess and Profm-,-sons Carie and my license is in full force and effect_ License#_ Expiration Date Date Contractor OWTIER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 031.5, 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 the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the ContraeLor's License Law(Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis far the alleged exemption. Any violation of Section 7031.5 by any applicant for a peanut subjects the applicant to a civil penalty of not mare than five hundred dollars($500)): ❑ 4 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 (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees, provided that such improveracnts are not intended or offered for sale. If, however, the building or 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 sale.) L1 1, as owner of the property, am exclusively contracting with Licensed contractors to construct the project (Section 7044, Business and Professions Code (B&PQ: The Contractor's License Law does not apply to ar, owner of property who builds or improves hereon,and who constructs for such projects with a contractor(s) licensed pursuant tr,the Contractor's License Law.) ❑ 1 am exempt under Section D&PC for tt-is reason _ Date: Owner WORKERS' CONITPENSATION DECLARATION I hereby affirm brat I have a certificate of consent to self-insure,or a cert-.ficate of Workers' Compensation Insurance,or a certified copy thereof(Section 3800, Labor Code). Expiration Date Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the Environmental Health Depwanent CERTIFICATE OF EXEMPTION FitONI WORKER.`;' COMPENSATION RNSUR-ANCE (This section need not be completed if the permit is for one hundred dollars($100)or less I certify that in the performance of the work for which this permit is issued,I shall not ernploy any person in any manner so as to hccorne subject to the Workers' Compensation Law, of California. Date: Aprlicant NOTICE 10 APPLICANT: If, after making this Certificatc of Exemption, yoo should become subject to the Workers' Compensation provision_ of the Labor Code,you must forthwith comply with such pro dsions or this perimt shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section 3097, Civil Code). Lender's Nanre Lender' Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION ❑ I hereby certify tha' no excavation five (5) or more feet in depth into which a person is required to descend, will be made in ........,,..+:.......; 1......�b ,... 5.,,.,-a.l 1...�1......ti...,.:♦ .....1 a1_.,a...,m,..a.l:......w,...r....� o..-.f%�1.-1 r.,.-. f I�e..r.-..L• '.r Aam nGY.nrfir.� em+a nflinn