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JOB ADDRESS:_ PERMIT#•
<br /> LICENSED CONTRACTORS DECLARATION.
<br /> I hereby affirm that I am licensed under the,provisions of Chapter 9(commencing with Section 7000)of Division 1of the Business and Professions Code,
<br /> and my license is in full force and effect.
<br /> License#!i`j ! 61, -f/ �( /E}xp.:Datc
<br /> Date Contractor -wK,
<br /> f
<br /> OWNER-BUILDS$DECLARATION
<br /> I hereby affirm that 1 am exampt from the Contractor's License Law for the following reason(Sec.7031.5,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 is licensed pursuant to rhe provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of
<br /> Division 3 of the Business and R ofessions 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 /> 0 I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale
<br /> (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-builder will have the burden of proving that he did not build or improve for the purpose of
<br /> sale.) i
<br /> i
<br /> XI,as owner of the property,am exclusively contracting with licensed contractors to construct the proiect(Sec.7044,Business and Profession Code:The
<br /> Contractor's License Law does not apply to an owner of property who builds or improves thereon,ana who contracts for such projects with a contractors)
<br /> licensed pursuant to the.Contractor's License Law.)
<br /> ❑I am exempt under Sec, B&P .for this reason
<br /> Date�m/1/4V Own `
<br /> WORKERS'ICOMPENSAI N DECLARATION
<br /> I 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.
<br /> Lab.C).
<br /> i
<br /> Exp.Date •v _Company ��
<br /> ❑Certified copy is heraby furnished
<br /> ❑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 hundred 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
<br /> Workers'Compensation Laws of California.
<br /> Date Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become sui)'ject to the Workers'Compensation provisions of the
<br /> Labor Cade,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(See.3097,Civ.C).
<br /> Lender's Name —
<br /> Lender's Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> ❑1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in connection with work j
<br /> authorized by the perm t,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,wilt be mure than thirty-six(36)feet
<br /> high. (Chap.3.2,Grp Art 2,Sec 341,Tide 8,C.A.C.).
<br /> 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such
<br /> person has a permit to do such work from the division.
<br /> ❑Division of Industrid Permit No.
<br /> I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws
<br /> relating to well constru=ction and or sewage syste nstruction,and hereby authorize representatives of this city to enter upon the above-mentioned property
<br /> for inspection purposes.
<br /> Date.�� Applicant ��
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