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Joe ADDRESS' PERMrr# LICENSED CONTRACTORS DECLARATION I I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Bun iess and Professions Code and my license is in full force and effect. License#_ Ezpiratiou Date Date Contractor OWNER-BUILDER DECLARATION I hereby affirm that i am exempt from the Contractor's License Law for the following reason (Section 7031.5, Bus' ss and Professions Code: Any:ity or county which requires a permit to construct,alter,improve,demolish,or repair any structure, rior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisio of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)o that be is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of not more than five hundred dollars($500)): ❑ L as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structur is not intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to owner of property who builds or improves !hereon, and who does such work himself or through his own employees,provided t such improvements are not intended or offered for sale. If,however, the building or improverner.i is sold within one year of co letion, the owner-builder will have the burden of proving that he did not build or improve for the puxpose of sale.) ❑L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044, usiness and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a con,ractor(s)licensed pursuant to the Contactor's License Law.) ❑I am exempt under Section D&PC for this reason Date: Owner WORKERS'COMMENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a ce.tificate of Workers'Compensation Insurance,or a certfied copy thereof(Sectiou 3800,Labor Code). Expiration Date Company ❑Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Deprrtment I CERTIFICATE OF EXEMPTION FROM WORKERS'CON11PENSATION INSURANCE (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 employ any person in any manner so as become subject to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to theorkers' Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall bedeemed r voked. I 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(Sec on 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION ❑I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend, will be nade in connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dist0antling thereof,will be mare than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,Catifo:nia Admirkstrative Code). ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial S fety, as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Permit# I certify that I have read this application and state that the above information is correct.I agree to comply with all city ancounty ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Date Applicant EHD 43-02-007 MASTER Water Well Permit Contractor Dt cl—iictim tv5a002