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.Aug-15-06 01 : 50P • • P.08 JoiRARDRESS: 11AN111114.• 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 Profeqsions Code and my license is in full force and effect- -53 oLp License A 6 8 Expiration Date _ � ' , a f7(] Date AW)U5t Contractor UUinn O(jam sfmotlu)lu OWNER-BUILDER DECLARATION I hereby affirm that I and exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ProfL%sions Code: Any city or county which requires a permit to construct, alter, improve, demolish,or repair any structure,prior to its issuance, also reqL61CS the applicant for such pen-nit to file a signed statement that he k 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 herefirom and the basis 1br the alleged exemption, Any violation of Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty()['not more than five hundred dollars($500)): [3 1, 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 tier sole (Section 7044., Business and Professions Code; The contractions License Law does not apply to all owner of property who builds or improves thereon,and who does such work himself or through his own employee-,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 sale.) [3 1, as owner of the property, illi exclusively contracting with licensed contractors to construct the prc�icct (Section 7044, Business and Professions ('ode (B&PC): The Contractor's License Law does not apply to all owner of property who builds or improves hereon,and who constructs for such projects with a contractors)licensed pursuant to the Contractor's License Law,) C1 I am exempt under Section B&PC for this reason [late: Owner-, WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers' C011111e)15ati011 Insurance,or a certified copy thereof(Section 3800, Labor Code), Expilration Date2��"!z Company 61ylot� -11, 1drCertified copy is hereby furnished 13 Certified copy is filed with the Lilyironincrital Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need n!),I,bL completed if the permit is for one hundred dollars($100)or less) I ceilify that it)the performance of the work for which this permit is issued, I shall not employ any person in any mariner so&%to become subject ject to the Workers-- Compensation Laws of California. Date:, Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fxemption, you should become subject to the Workers' Compensation Provisions of the L.1ibor Code,you must forthwith comply with such provisions or this permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is construction lending agency for the performance ofthe work, for which this permit is issued(Section 3097,Civil Code), Lender's Name Lender' Address