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J0e ADoREss:
<br /> _.._ .....�_ PERMIT E7
<br /> LICENSED CONTRACTORS DECLARATION
<br /> nerepy affirm!fife:I Ar,lcansod under Ive crovisions or Cnaplar 9 Ico,rn enL::,g•wdi,yea c;•+70g0;CI ClvLslcn]alma 9.rsrnYss aM
<br /> Prafaeswns Cdas and m71.ICen yp it,^hr,l toren and enar.
<br /> License406
<br /> _ Ex
<br /> Date 4piration Dale _�� l� _i
<br /> DaGontrutor
<br /> OWNER-BUILDER DECLARATION
<br /> herepy uMrm rhe(;am ase+rpt from live Cs•Uac!ors.conso"w icr trx'acnw�nq reason iSec NOn*01'S,9us,roas and?tnleaa.O•ra t
<br /> Code Any city of:aunty which requites a perm t!a cc struCf.aRer..m prove aernohsn,Or reparf any slntc!.to prior 10 as,sSuanCe.
<br /> also requires the adol-Cant tot such permit ro%a st"d atatemert that no a!tensed pars,ranl to the prov war$01!1,0 Contraclo•'s
<br /> _:cense Law ICrapler 9'commenc-ng with Sector 7000)of D-Aeon;I cf the 9uliness and P'O'aswns C;Oda;Or Thal he 9 allompt
<br /> nerahornparal rw Davit for the alleged esenlpton Any ylcaho at SArllen'CIT-05 fly any app•Cant for a parml(16b)ecls:no'Applicant
<br /> to a Uv41 ry,at'M mom Inar rid Rundred dollars(550017
<br /> 0 1 as Owne'of fro Drope•ly,or my emoloyees war wages a5!he,r Yalu cumpens400r,wai do tmo Nati, ]1,0 Ina struc!ura Is not
<br /> "'C"000 Or 011C(IM for Sala fSdttwn 1`044,8.4woss and Professors Cade Trle COAMICtOre L
<br /> S L-CensTw does nbt it ln
<br /> Owner Of property who oua0s Or,morovas morean•ant wno does svcn ,mwm
<br /> work nsolf 0,(I'n>,gb h,s ar epAoyoes,provided0 av'aa
<br /> such r 1200yernlrrOS are re::,funded or oPII for sale f h0wnvar. Ito buYdleq or•mOrovelnent'a said wlfmn one fee,at
<br /> �omoloben.m0 owner.builder"t nave Me ouraen Of atOVlftq III 1,e did not Ou,la at mipraM fur Ire pL,rposo of sale
<br /> I,as O'arnar aline propory,am CetluaWelT COwtra ling with I96RSCd Contractors fillCanlrtba IM 0101eC!ISernOrl 7044.13 uslnf!ss And
<br /> PlufesS,OnS Cede(B&PC) The:Dntflre:at'l Lienee..aw deal net dally IO an Owner oI p'�paml'wM Oul As Or imPra vas re•eon,
<br /> AM who COMIrYCrs rot s6Ch prOpCll with a co ntlOCIM(1)Itersnd.L-(suanl to•R8 COntfaUars L'oonpa Law)
<br /> am OuamPt a-,ser sacfron UPC for this_edso,.
<br /> Data; Owner. J , 4�
<br /> WORKERS'COMPENSATION DECI.ARATION
<br /> I hereby affimn that I have a aarUState of Consent to self insure lir a certificate or Workers'COmponsabon Insurance,or a
<br /> Certified copy thereof(Section 3800.Labor Code)
<br /> Expiration Date Company.._.. .
<br /> 0 Codified Copy Is nereoy rtarmishod _
<br /> r
<br /> f]Certified Caapy.s flied with the Environmental Ieatth Ceparlmunt
<br /> j
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> l f Th's 4'L�n_rwau not t�0..0!^Dt9ted it the Pe—t,s tot 9ng Its./gS�I�Ca j$1QG].or j@59J
<br /> I Certify that In the pedOrtrwncu of the work for WMiCh(1,,s permit s Issued I&hall not employ any person n any marnior so
<br /> as to become subject to the Workers'Campansatlon Laws of Cawomla 1
<br /> Applicant
<br /> NOTICE TO APPLICANT If anar mak,rg tn,s Certificate lir csen•ptiOn yob snuuta Oecome wolact:o d•a Work
<br /> O'1'C:anptlnaalbn
<br /> r1rovivans at the.scotoda
<br /> C you must(CM7nwdh Comp1Y wr10 such pmusin rs or•his pe m,4 shat•a0 dCRmpo'evdsod
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm Ina(there.S a CenStrluction'endlrteJ agency for'tie performance of(he wo-k for wrich Ihls permit Is ISSLed
<br /> (Section 3097.Cwt(Coda)
<br /> Lenders Name
<br /> Lander Address
<br /> I '
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> nereby comfy mat no escayahbri five(51 rn mare'ea; „depth into-n Ch a perSOn Illu,
<br /> a
<br /> ' 0 tea to Oo m3lti Urn
<br /> en e Omane
<br /> P.
<br /> ^mmnr.!aan vnm work dullMrtree Dy Ina pmntii and loaf ria Mr•]trig stm,du'A scaffoq,rLq Ie.sewOrx.or o11TOPtgn or dsntl r+g
<br /> thereof,w11 be nom!flat,th,ny.bs(30'I feet nigh (:ha0100r-12 GM-111 t',AncV!i. Secltori AV "?a B,California Admmislrahve
<br /> :ride)
<br /> i
<br /> i! 4ff As OWnSt-OL IklOf I wt rot employ anyone to do wore wnten wouil rgc,lfa a;.omn tram TM U rirlon 41 4,d4soist Safet
<br /> above•UnTals 11I person nal a parlrif to do 9,,-R NCrk item IRA dives gar, y as natOO
<br /> I0 Div Sion of Irdustral Salwy Parini!e
<br /> I car(ly trial rave read '.his apparal,on and slate Ina(Ine a0ove In10(malon s COrrtlK agree,p,•o.npiy war at,ay Arid•;aunty
<br /> ardYlamea and Y!Ytil IYwa•Yltluny to will 09"501, Oun and w lewaye sySWni cdr+sv t to av to MWolentaWal Of this
<br /> COunly 10 area'-Pon the aboL,O menhorK,d Propor:y to,�naaec Aar"Casey
<br /> Dote �y— 1r Applicant
<br /> GHJ 1.4.7f
<br /> ^•sv; -:L%tike;
<br />
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