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JOB ADDRESS: PERMIT a:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,
<br /> and my license is in full force and effect,
<br /> License N Exp..-Dare
<br /> Date_._
<br /> OWNER-BUILDER DECLARATION
<br /> 1 hereby affirm that I am exempt from the Contractor's License Law far the following reason(Sec.1031.5,Business and Professions Code; Any city or
<br /> county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
<br /> to file a signed statement that he i¢licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(coricnencing with Section 7000)of
<br /> Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by
<br /> any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> 13 I,as owner of the property,or my ernriloyees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale
<br /> y (Sec.7044,Business and professions Code.:The Contractor's License Law does not apply to an owner of property,who builds or improves thereon,and who
<br /> does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If,however,the building or
<br /> improvement is sold within one year of completion,the owner-huddeT will have the burden of proving that he did not build or improve for the purpose of
<br /> sale.)
<br /> U L as owner of the property,am exclusively conti-acring with licensed contractors to construct the project(Sec.7044,Business and Profession Cote:The
<br /> Contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)
<br /> licensed pursuant to the Contractor's Lioense Law.)
<br /> CI 1 am exempt under Sec. —,B&P.C.for this reason
<br /> Dau Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affiant that 1 have a certificate of consent to self-insure,or a cen3frcate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,
<br /> Lab.Q.
<br /> Exp.Date Company _
<br /> O Certified copy is hereby furnished
<br /> CI Certified copy is filed with the County Building Inspection Division
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed,if the permit is for one hcndred dollars($100)or less
<br /> 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 tot he JJJ
<br /> Workers'Compensation laws of California. j
<br /> Date Applicant ifl
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject}o the Workers'Compensation provisions of the f
<br /> Labor Code,you must forthwith comply with such provisions or this permit shall be deemed vevoka,
<br /> I I4 .3
<br /> CONSTRUCTION LENDIWY AGENCY',
<br /> I hereby affirm that there is a construcaoa fending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C) 4
<br /> Lender's N:mte _-- — --
<br /> l
<br /> Lender's Address -------------
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> CI 1 hereby certify first no excavation rive(5)or mote feet in depth into which a person is required to descend,will be make in connection with work
<br /> authorized by the permit oral that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet
<br /> high.(Chap.1Z Grp 2,Air 2,Sec 341,'ntle S.C.A.C_).
<br /> ` 4 As owner-builder.I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as rioted above,unless such
<br /> parson has a permit to do such work from the division. ,
<br /> (! ❑Division of Industrial Permit No._
<br /> I certify that I have read this application and state that the above information is cortect. I agree to comply with all city and county ordinancis and state laws ,
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this city to enter upon the above•mcationed property
<br /> for inspection purposes.
<br /> t
<br /> Date Applicant
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