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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm!hat I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Profrssions Code, and my license is in full force and effect. License N _ Exp.:Dau_ Date Coniracior OWNER-BUILDER DECLARATION I hereby affirm that 1 dm excmht from the Contractor's License Law for the following reason(Sec,7031.5,Business and Professions Code: Any city or county which requires a permit to construe,,alter,improve,demolish,or repair any structure,prior to its issuance,also rcgt!tres 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 7000)of Division 3 of the Business and ProfeSJlons Code)or that be is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (a5(K))): i ❑I,as owner of the property,or my emp!oyees with wages as their sole compensation,will do the work,and the s.iructure is not intended or offered for sale (Sec.7414,Business and Professions Cotle,The Contractor's License Law does not apply to an owner of propeny who builds or improves thereon,and who does such work himself or through his own e..-nployces,provided that such improvements are not intended or uffertd for sale. [f,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 1,as owner of the property,am exclusively contrecting with licensed contractors to construct the prujxt(Sec.7044,Business and Profession Corte:The Contractor'%t.icense Law docs not appty to an owner o(pmVerty who builds or improves thereon,ane'.who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) I am exempt under Sec. R&P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self-insure.or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800, Lab.C). Lxp.Iltie Company _ +. O Cenified copy is hereby furnished ❑Certified copy is filed with die County Building Inspection Divisioar CERTIFICATE OF EXEMPI7ON FROM WORKEP.S'COMPENSATION INSURANCE r'fhis section need not be completed,�f the peanut is for one hu!dred dollars($100)of less, 1 Li 1 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 10 bexome suhject tot be :# Workers'Compensation Laws of California, Date Applicant c NOTICE TO APPLICANT:If.after making this Cenificale of Exemption.you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall he deemed rrvoKcd. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction I_nding agency for the performance of the work for which this pe;mit is issued(Sec.3097,Civ.C). :f �I Lenders Name.___ M Lender's Address_- . — M DIVISION OF[YDUSTRiAI.SAFETY PERMIT CERTIFICATION: � 12 t hereby certify tMu no excavation five(5)or more feet in depth into which a person is requited to descend,will be make in connection with work authoriLed by the permit.and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2.Grp 2.Art 2.Sec 341,title 8,C.A.C.). ❑As owner-builder,f will nor employ anyone to do work which would require a permit from the Division of Irtduslnal Safety,as noted above,unless such person has a permit ro du such work from the division. ❑Division of Inaustrial Permit No. i 1 certify that 11 have read this application and nate 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 system construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. Datc_ Applicant i