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JOB ADDRESS: PERMIT M.
<br /> r L-44f
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hetebyaaffirm that I am licensed under�the provisions of Chapter 9(commencing wifl' esti fn 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 /> OWNER-BUILDER DECLARATION
<br /> r
<br /> I hereby affirm that I am exempt from the Contractors License Law'for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires,a permit10 construct,alter,improve,demolish,or repair any structure,prior to
<br /> O 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 /> 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 /> T ❑I,as`owner of the property,or my employges with wages as their sole compensatioty will�do the�work,and the structure is not
<br /> .i intended or offered for sale(Section 70 ,Business and Professions Code:The'coitractor's License Law does not apply to an:t
<br /> i owner of property who builds 44or 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 /> r 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 propery who builds or improves
<br /> 51.
<br /> 't1 hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> 5 ❑I am exemptunder 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 /> O Certified copy is hereby famished
<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 hundred dollars($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
<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 the Labor Code,you mtuustt ffo�rtthwith comply with such-provisions or this permit shall be deemed revoked.
<br /> ... . �l �,1�p� �."1`l.l.r1 4�\�-�t;e:�i�1'�
<br /> 13 a�CONSTRUCTION LENDING AGENCY_.
<br /> I hereby affirm that there is'•a co_nstructton,lending ageneykU the perfo I ce of the_work for which this permit is issued.(Section
<br /> 3097,Civil Code). _ I u ! a
<br /> Lender's Name _ {it ------t 1
<br /> Lender'Address ! V
<br /> 77—
<br /> DIVISI6N bF INDUSTRIAL SAFETY PERMIT C TICATION•
<br /> ❑ I hereby certify th3Yno excavation five(5)or more:feet-an dep4Cin`}o whir a person rs;requrr`ed`to-emend, will'be made in
<br /> connection with work authorized by the permit,and that:no buildin&structurea,scaffolding,falsework,or demolition or dismantling
<br /> thereof,will be more than thirty^six(36)feet high�(Cliapt�ei 3.2 GrouQ2;9nc�e 2,Section 341,Title:8,Califointa�dtrlir�istrative_
<br /> ._. Code). _.
<br /> 11, ❑AS.owner- I will not employ anyone to do.Work wluch�would require apertnit from.tyD�Sion of Industrial Safety,as
<br /> noted above,unless such person has a permit to do such�vork.from the divi ion.
<br /> ❑Division of Industrial Safety Permit#
<br /> r.
<br /> I certify that'IIia ve read this applicatiofi=and state flint tfie abOve iaformandri correct.I armee to compTy;Witti'all city and county
<br /> ordinances and state,laws relating to well-construction and or sewage systet ,0iistruetion,and hereby authorize representatives of this
<br /> county to enter upon the above-mentioned property,for inspection purposes._ c,` v :t
<br /> Date Applicant_
<br /> EHD 43-02-007 r t
<br /> 12r11/200Z ��,^ t` 1 a' {ICENS6DCONTRACTORSDECfARATiON E
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