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JOB ADDRESS: 111{1, Q,� f T� .C� PERMIT,, 3 14 vJ
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 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
<br /> in full force and effect. Vat
<br /> License# 6Lr 7 "�L� t /�� Expiration Date C
<br /> Dat Contractor /`y /-
<br /> le-
<br /> OWNER-BUILDER DECLARATION
<br /> 1 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
<br /> 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
<br /> he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)
<br /> 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
<br /> of not mon:than rive hundred dollars($500));
<br /> b 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 for sale(Section 7044,
<br /> 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
<br /> 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
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon,and
<br /> who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑1 am exempt under Section , B&PC for this reason
<br /> Date: Owner
<br /> WORKERS' COMPENSATION 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(Section 3800,Labor
<br /> Code),
<br /> Expiration Date Company
<br /> O Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars($106)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 to the Workers'
<br /> Compensation Laws ofCalifomia.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,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(Section 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 13 I 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 work authorized by the
<br /> permit,and that no building structure,scaffolding,falscwork,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chapter 3.2,Group 2,Article
<br /> 2,Section 341,Title 8,California Administrative Code).
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit#
<br /> I certify that I have read this application and state that the above Information Is correct.1 agree to comply with all city and county ordinances and state laws
<br /> relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property
<br /> for inspection purposes.
<br /> Date Applicant
<br /> EHD 43-02-007 Licensed Contracton Dmlmtion.dm
<br /> V 1412003
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