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JOB ADDRESS: I.3�Q! 14�j/ +� — PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 ofthe Business
<br /> and Professions Cordae and mv_license is in full force and effect.
<br /> License# `f 3 Expiration Date- 3
<br /> Date —d L-- Contractor 6,*,E 71- ri.
<br /> OWNER-BUILDER DECLARATION
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<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 I_aw(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is 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 /> ❑ I, as owner of the property, or my employees ivith wages as their sole compensation, will do the work, and the smicture is not
<br /> intended or offered for sale(Section 7044,Business and Professions Code:The contractor's License Law does not apply to an owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such
<br /> 1 improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion,
<br /> 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 exclusive:y 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 hereon,
<br /> 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 _
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<br /> Date: /�' 3— �� 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 Depaament
<br /> CER'T'IFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars 1001 or less
<br /> I certify that in the performance of the work for which this permit is issued,I shall ant 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, alter making this Certificate of Exemption, you 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 /> CONSTRUCTION LENDING AGENCY
<br /> 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code)-
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ 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
<br /> connection with work authorized by the permit, and that no building structure,scaffolding, falsework,or demolition or dismantling
<br /> thereof,will be mere than thirty-six(36) feet high- (Chapter 3.2,Group 2,Article 2, Section 341,Title 8,California Administrative
<br /> Code)-
<br /> 13 As owner-builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
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<br /> I ❑Division of Industrial Safety Permit
<br /> I certifv 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 cons(niction 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
<br /> EH[)43-02-007 MASTER Water Well Permit Contractor Declaraction
<br /> 5i2gn002
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