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i JOB ADDRESS: PERMIT'M LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License# Expiration Date Date Contractor OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code: Any city or 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 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 Professions Code)or that he 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($5W)): ❑ I.as owner of the property, or my employees with wages as their sole compensation, will do tine work,and the structure is not intended or offered for sale(Section 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 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 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 salt.) ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(B&PC): The Contractor's License Law does not apply to an ownrr of property who builds or improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) 111 am exempt under Section MPC for this reason _ Date: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that i have a cerrificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date Company ❑Certified copy is hereby furnished ❑Certified copy is filed with the Environmental Health Depa:tmcnt CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(519)0 or less I certify that in the performance of the work for which this pernut is issued,I shat!not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Date: Applicant NOTICE TO APPLICANT: If after rwking this Certificate 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 be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constrixtion lending agency for the performance of the work for which this permit is issued(Section 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL.SAFETY PERMIT CERTICATION ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with wofk authorized by the permit,and that no building structure,scaffolding, falsework,or derrwhtion or dismantling thereof, will be more than thirty-six(36)feet high.(Chapter 32,Group 2,Article 2,Section 341,Title 8,California Administrative Code). ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Indu--trial Safety, as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Pemut art 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 relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Trate Applicant EHD 43-72-)07 MAS]LK Water Wcll Pernit Contractor DUxtaracti n 1VSr2(x12 — -•--- --- --