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i. JoBAoDRESs: PERMIT#:
<br /> LICENSED CONTRACTORS D,-," R. TION-
<br /> I hereby affirm that i am licensed under the provisions of Chaptcr 9(commencing with Section-7000)of Division3 of the Business
<br /> and Professions Code and my license is in full force and effect.
<br /> License# 1 ' Expiration Dale
<br /> `\Date t Contractor >y
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that 1 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 be
<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(5500)):
<br /> ❑ 1, as owner of the property,or my employees with wages as their sole compensation, will do Ilse 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 properly 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 /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the proj,-gt ection 7044,Business
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who'buiIds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> Cl I 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
<br /> copy thereof(Section 3800,Labor Code).
<br /> Expiration Date Company
<br /> ❑Certified copy is hereby furnished
<br /> ❑Certified copy is fit d with the Environmental Health Department
<br /> CE TIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars(1100)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
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: "If, after making this Certificate of Exemption, you should become subject to the Workers'
<br /> Compensation provisions of tltc Labor Code,you must forth%vith comply with such provisions or this permit shall be deemed revoked.
<br /> I
<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
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> Di VISION NDUSTIUAL'SAFE'TY"PERNIIT CERTJCATION——
<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 more than thirty-six(36)feet high.(Chapter 3'2,Group 2,Article 2,Section 3.41,Title 8,California Administrative _
<br /> Code). + _
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of indtistrial Safety,as
<br /> noted above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Ihdustrial,Safety Permit#
<br /> L. - ALi
<br /> �. I certify that Lhavti read this:application-and state that,the above6tiformation'is correct-1 agree to comply with all city and county
<br /> ordinances and state laws relating to well constructioh and or sewage'sy'stem'construct ion,and hereby authorize representatives of th(s— T_
<br /> county to enter upon the above-mentioned property for inspection purposes. --
<br /> Date L` �'I APPlicarit ``
<br /> EI ID 43-02-007 t-ICFNSFD CONTRACTORS DECLARATION
<br /> 12,111/2002
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