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<br /> J 7B ADDRESS:_ PERMIT#:
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby.farm that I am licensed undcr rhe provisions of Chapter 9(commencing with Section 70W)of Division 3 of the Business and Pn,fcssrooa Code,
<br /> and illy license is in full force and effect,
<br /> License#—. _E-xp.;Datc
<br /> Dal c_ Comiracmr_
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that i alit cxunpt frorn the Contractor's License Law for the following reason(Sec.7031.5,Business and Preic�ssions Code: Any city or
<br /> county which requites a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
<br /> i 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
<br /> Division 3 of the Business and Proressions Code)or that he is exempt hcrcGom and the basis(or the alleged cxcmption. Any violation of Stenon 7031.5 by
<br /> any applicant for a permit subjects we applicant to a civil penalty of not more than five hundred dollars(5500)):
<br /> O I,as owner of clic property,or my cmuloyecs will,wages as their sole compensation,will do the work,and the awcture isnot intended or offered for sale
<br /> (Sec.7(A4,Business and Professions Cock:Tlhe Contractor's License Law docs not apply to an owner of property who builds or improves thereorh,ant]win
<br /> docs such work himself or through his own employees,provided that sech improvements arc not intended or orfered for salt. if,however,rhe building or
<br /> improvement is sold within one year of contpulion,the owner-builder will have the burden of proving that he did not build or improve lot the purpose of
<br /> sale.)
<br /> 111,as owner of the property,am exclusively cotuacting with licensed contractors to construct the proicet(Sec.7044,Business and Profession Code:The
<br /> Contractor's License Law docs not apply to an owner of properly who builds or improves thereon,and who contracts for such projects with a conlraclor(s)
<br /> licensed pursuant to the Contractor's License Law.)
<br /> 1711 am exempt under Sec._ ,B&P.C.for this reason
<br /> Date_ Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hueby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Couhpensauon Insurance,or a certified copy thereof(Sec 3800.
<br /> Lab.Q.
<br /> Exp.Date Company _.
<br /> ZI Ccrtdicd copy is hereby furnished
<br /> ❑Certified copy is Filed with the County Building lnspectinn Division
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need nut be completed,if the permit is for one hundred dollars(S 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 tin lire
<br /> Workers'Compensation Laws of Califomla.
<br /> Date___.__Applicant_
<br /> NOTICE,TO API'LICANT:If,after making this Grtif talc of Exemption,you should become subject to the Workers'Compensation provisions of die
<br /> l ahor 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 larding agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C).
<br /> Lender's Name _ _
<br /> Lender's Address_
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br /> ❑Thereby certify that no exce.vation five(5)or more feet in depth into which a person is required to descend,will be make in cunnecrion with work
<br /> awhurized by the penni6;rod that no building swcturc,sea(folding,falsework,or demolition or dismantling thereof,will he more than thirty-six(36)feet
<br /> high, (Chap.3.2,Grp 2,AT(2,Sec 341,Titic 8,C.A.C.).
<br /> ❑As owner builder,I will not employ anyone to du work which would require a permit from the Division of Industrial Safety,as nowt above,unless such
<br /> person has n permit to do such work from the division.
<br /> ❑Division of Lrdustnai Permit No.
<br /> I certify t'rhat 1 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 wrii construction and or sewage system consuuctiou,and hereby awhurize representatives of this county to enter upon the above-mewtoned
<br /> property for inspection purposes.
<br /> Date_ _Applicant--
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