|
JOB ADDRESS: PERMIT#:
<br /> t_7:-rt: L
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I heteby�affum that I am licensed under the provisions of Chapter 9(commencing widi'Sectibn 7000)of Division 3 of the Business
<br /> and Professions Cde and my license is in full force"and effect. -
<br /> License# �) ' "1 Expiration Date
<br /> Date Contractor
<br /> i 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 requiresa periut.to co'i stiuct,alter,improve,demolish,or repair any structure,prior to
<br /> (l 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 /> ❑I,as`owner of the property,or my employees:with wages as their sole compensation;;wil[Pdo-the work,and the structure is notAl
<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 propery who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor'sLicense Law.)
<br /> (J ❑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 /> 0 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 completedif 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 must forthwith comply with suchl3rovisions or this permit shall be deemed revoked.
<br /> r_ Nt.. t3,�'1
<br /> ~�1 �y 31 rl l..cj 1 1 I f I J �-v I i i 3?•1
<br /> c a CONSTRUCTION LENDING AGENCY' ,
<br /> htT, rm _.
<br /> Ra hereby affirm that there a construcdon,lending.agency f the performance pf—e work for which this permit is issued:(Section
<br /> 309.7,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF"INDUSTRIAL SAFETY PERMIT CeATICATION
<br /> ❑ I hereby certify tlsat no excavation five"(5)of inoie.feed";in dep4 into wlucEi a person is,:require�to+ascend,will'be'made in
<br /> connection with work authorized by the permit,and t t:no building s"ct4reJ scaffolding,falsework;or demolition or dismantling
<br /> thereof will be more than thitty�six(36)feet high.,(Chapttei 3, Groitp 2'Arfiae 2,,Section 341,,Title_8,Cali_fo_mia AdrL Qistrative__
<br /> Code) W\
<br /> E3A's weer-builder,I will not employ anyone to do work Wch Fould require to permit fiom."t�me'Divvision o Industrial Safety,as
<br /> 1 noted above,unless such person has a permit do such kork'from the dim i ion.
<br /> vx;,.�_."�•. ems:+•'.,, ...``
<br /> ❑Division of Industrial Safety Permit# V
<br /> I'certify thaid-Have read this application anti state that the above iiifommah�h�correct.I agree to comply-with'all city and county
<br /> ordiaances and state-laws relating to well construction and or sewage systetn construction,and hereby authohn representatives of this
<br /> county to enter upon the above-mentioned property,for inspection purposes.
<br /> Date y Applicant
<br /> EHD 43-02-007 .. i-
<br /> 12/11/2002 .LICENSED CONTR14CrORS DECLARATION
<br />
|