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<br /> JOB ADDRESS: 2Y 774 S- I/.,y U p 1111/' _ 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 3 of the Business
<br /> I/and Professions Code and my license is in full force and effect. t
<br /> ( License# 73773r r Expiration Date
<br /> 1 Date Q�� Contractor We51f– ��rf Syn r Eek < 1)O�3 ee-sk-v 4--(ec)(i•L
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the,following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to
<br /> its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> his exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
<br /> the applicant to a civil penalty of not more than five hundred dollars($500)):
<br /> ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code: The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that
<br /> 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 /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> ❑I am exempt under Section B&PC for this reason
<br /> I
<br /> Date: 03 11W<2 7 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
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑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•hundreddollars($100)orI Iless)---
<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
<br /> become subject to the Workers'-Compensation-Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: If, after making this Certificate ofrExemption,.youu 'should become subject to the Workers'
<br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> 1
<br /> CONSTRUCTION LEN I ING AGENCY I I
<br /> t
<br /> I hereby affirm that there is a construction lending agency for the performance off the rk for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name +
<br /> Lender'Address I
<br /> i DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 0 I hereby certifythat no excavation five(5)-or.more feet.in-depth-into.which a-person is required to descend, will be made-in—
<br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling
<br /> .\ thereof,will be more than thirty-six(36)feet high.(Chapter 3}2,Group 2,Article 2,4,Section 341,Title_8,California Administrative
<br /> Code). t
<br /> ❑As owner-builder, I will not employ anyone to do.work,which would require-&permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division. Y�.
<br /> ❑Division of Industrial Safety Permit#
<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
<br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Date Applicant f f- -
<br /> EIID 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> 12/11/2002 ,
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