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JOB ADDRESS: fly RVIT#:
<br /> LICENSED C'ONTRA('I ORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chat l,i'r lcommencing with Section 7000)of Division 3 of the Business
<br /> and Professions Code and my license is in lull force and effe n
<br /> License#_^. _ Expiration Date
<br /> Date Contractor
<br /> OWNER-BI:I l DF R DECLARATION
<br /> I hereby affirm that ! am cxenmpt from The Contractor's I ; ,•. Law for the fiollow•im, reason. (Section. 7031.5, Business and
<br /> Professions Code: Any city or county which requires a perm.m!,-.. lstruct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant(br such permit to file.,,: •ted statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Sect:•m -1-110)ol'Division 3 of the Business and Professions Code)or that he
<br /> is exempt hercfrom and the basis for the alleged exemption. No. .iolation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penally of not more than live hundred d.-:U-i S`00)):
<br /> ❑ T.as owner of the property, or my employees wall t+age;,t, il-oir rule compensation, will do the work,and the structure is not
<br /> intended or offered for sale(Sreuon 7044. Business and 'na,,;tons('ode:The contractor's License Law does not apply to an
<br /> owner of property who builds or Improves thereon,and who d...,such Work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. I!: wvrever. the building or improvement is sold within one year of
<br /> completion,the owner-builder will lia%-C the burden of Arm u_•1,:u he did nor build or improve for the purpose of sale.)
<br /> ❑ L as owner of the property,am exchrsht.;.ly cuntractuig tont:h,rnsed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(ISKP('): The Contractor's License I.nr Joes not apply to an owner of property who builds or improves
<br /> hereon.and who constructs for such projects with a contra: ;licensed pursuant to the Contractor's Incense Law.)
<br /> ❑1 am exempt under Section B&VC for Ili,.,.;:•nm
<br /> Date: Owntr
<br /> WORKERS' rION DECLARATION
<br /> I hereby affirm that 1 have a certiticate of consent to self insur, certificate of Workers'Compensation Insurance,or a certif ied
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date, ('outpany
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Fn%irtuinleulal Health Dep;wow;
<br /> CERTIFICATE OF EXEMPTION FROM%%A)RKF.RS'CONIPENSATION INSURANCE
<br /> {This section need not be completed if fhe pernut jLLoEpne but,lrs,:.lollars . 1001-2r less
<br /> 1 certify that in the performance of the work for which this per oil •i,sued.1 shall not employ any person in any manner sn as to
<br /> become subject to the Workers'Compensation Laws ofCalifitt.,,,,
<br /> Dale Applicant _
<br /> NOTiCE TO APPLICANT: 11, alter making this C'ertir caie of Exemption. you should become subject to the Workers'
<br /> Compensation provisions of the labor Code.you must forthw int-[-,ply with such provisions or this permit stroll be deemed revoked.
<br /> CONST RUCTION LENDING AGENCY
<br /> I hereby affirm that there is it construction lending agency for 11 c I•.;::ior ranee of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Leader's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL s:NFFTV PERMIT CERTICATiON
<br /> ❑ 1 hereby certify thrt no excacatron live(5) or mire feet a::Iclsh into which a person is required to descend, will be made in
<br /> connection%%ilh pork autlwrited by the permit,and that nu in.ddumg structure,scaffolding,talsework,or demulition or dismantling
<br /> thereof,will be nx)rc than thirty-six(30)fret high.(Chaplet 3' -iroup 2,Article 2,Section 341,Title 8,California Administrative
<br /> Code).
<br /> Cl As owner-builder, 1 will not employ anyone to do work wlu.h would require a permit from die Division ol'Industrial Safety,as
<br /> noted above,unless such person has a permit to do such w•urk Ii•,rn the division.
<br /> ❑Division of Industrial Safety Permit,'!
<br /> 1 certify that l have read this application and state that the ah,itc intbrmation is correct. I agree to comply with all city and county
<br /> ordinances and state laws relating to well construction and or Shwa h system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned properly for inspection purposes.
<br /> Dale .Npplicant
<br /> El ID 41-02-00' 1.VIINSU)CONTRACTORS DECLARATION
<br /> 12-1 1.2002
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