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JOB ADDRESS: PFRMIT#: i
<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 /> and Professions Code and my license is in full force and effect,
<br /> License# Expiration Date
<br /> Date Contractor
<br /> ONVNXR-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(cormnencing 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 titanfive hundred dollars($500)):
<br /> ❑I,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 owner
<br /> of property who builds or improves thereon, and who does such work himself or through his own employees,provided that such
<br /> improvements are not intended or offend 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 purposeofsale.)
<br /> ❑1,as owner of the property,am exclusively contracting with licensed contractors to coratruct the project(Section 7044,Business
<br /> and Professions Code(B&PC): The Contractcr'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 /> 17 I am exempt under Section B&PC for this reason
<br /> Date: Owner
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<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 /> Q Certified copy is hereby furnished
<br /> .0 Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION.FROM WORKERSN'COMPENSATION INSURANCE
<br /> (This section creed riot be complegd"f the nermit is or one hundred dollars($100 orless)
<br /> I certify that in the performance of tl t work for which this permit is issued,I shall not employ anyvson in any manner so as to
<br /> become suBjWfio thl'.-Workers:Con qxnsafion Laws of California:
<br /> Date; i _ Applicant
<br /> NOTICE TO APPLICANT_ If, after making,this Certificate of Exemption, you should become ,Iubject to the. Worersk '
<br /> Compensation provisions of the Labtr Code,you trust forthwith comply with such provisions or this permit shill be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY `
<br /> I hereby affirm that there is a construction lendinvagerky for"the perfoini=ce df the work for which this permit is issued(Section
<br /> 3097,Civil Code). i
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<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 17 1 hereby certify that no excavation five(5) or more feet in deptil into which a person is required to descend,will be trade 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-sx(36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,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 Industrial Safety,as
<br /> noted 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.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 /> Dote Applicant
<br /> E11D 43-02-007 MASTER Water well PennitCmtractor Daolaraction i
<br /> 1 2/5,2002
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