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i Jou ADDRrss: PERMIT 0: LICENSED CONTRACTORS DECLARATION I heieCy aNum that I am licensed under the provisions of Chapter 0(commencing with Section 1000)of Division 3 of the Business and Professions Code and my license:s in full force and effect License k 90859: Expiration Date 1/ 11:016 Date 211712016 Contractor — OWNER-BUILDER DECLARATION I hereby affirm Quit I am exempt from the Contractor's L KANISC l aw for the following reason(Section 7031 5.Business arid Professions Code Any city or county which requires a permit to construct.altar,improve,demolish.or iepau any structure,prix,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 Contractor's License Law(Chapter 9(commencing with Section 1000)of Division 3 of the Business and Professions Code)or that tie is exempt nerelrom and the basis for the alleged exemption Any vioiabon of Section 7031.5 by any applicant for a permil subjects Inc oppicant in.)civil penalty of not mn•e than five hundred dollars(5500)) ❑I,as nvinnr of Inn property,nr my empWyees with wages as their sole cornpursat un,will du the work,and the structufe tt not intended or offered for sale(Seulun 7044.Busines5 and Pruressiuns Code.Tiw cuntiactur's License Law does not apply to an owner of property wtio builds or improves thereon,and who docs such work himself or through his own employees,provided that such improvements are not mended or offered for sale. If, however, the building or Improvement is sold within one year of completion.the Owner-buiWer will have the burden of proving that he did not build or Improve for the purpose of sale.) �1b I.as owner of the propertyam crdusrvely contracting wwdh licensed contractors to construct the proect(Section 7044,Business and Professions Code(BdPC) The Contractor's License Law does not apply to nn owner of property who builds or improves hereon. and who constructs for such protects with a eontraclor(s)Incensed pufsi to the Contractor's License Law.) ❑1 am exempt under Section BdPC for this reason Date: 2:17/2n1% --- — Owner I WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell msure or certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800.Labor Code) Expiration Date 11112017 Company ;rave:rr_: ❑Certified copy is hereby furnished )0 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completedif f the permit is_fQrn hundred dollars(5100)or less) 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 file Workers'Compensation laws of California. Date: __ Applicant — NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should become subdect to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I I hereby affirm that there is a construction lending agency for the performance of the work for which this pormit is issued (Section 3097,Civil Code) Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION I hereby certify that no excavation five It))or more feet In depth Into which a person Is required to descend, wiC be made In connection with work authorized by the permit.and[hal no bulldog structure.scaffolding,lalsework,or demolition or dls-nant6ng thereof,will be more titan thirty-six(36)feet high.(Chapter 3.2.Group 2.Article 2,Section 341,Title 8,Californin Admnishative Code) ❑As owner-builder.I will mf employ anyone to do work which would require a permit from the Division of Industrial Safety.as noted above,unless such person has a permd In dr,such work from the division ❑Dvislon of Induslnal Safety Permit A - I certify that I nave read this application and stale that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage systcrt construction,and hereby authorize representatives of this county to enter upon the anove-mentioned oroperty for inspection pugonscs Date 2.i71J0:c Applicant � LIQ a01 LICLMJLQ GOWI ACTOR[tFCAARA]ION! tn'�u1