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Joe ADDRU< Prmar0:
<br /> RS233
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(oemmmdng with Section 7000)of Division 3 of the Business and
<br /> Profession Code and my licence Is In full force and affect
<br /> Lkenas N ,3j2 84r{ Expiration Dab
<br /> Date 4/-7 J.Z.O IZ Contractor PcL3 N4taJ T�ENgaJCr�.
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby Allen that l am exempt from the Contractor's Llwnee Lew for the fotowng meson(Section 7031.5,Business and Profeesions
<br /> Code: Any,c y or county which requires a permit to construct,after,Improve,demolish,or repair any struduro,prior to Ba Issuance,
<br /> also requires the applicant for such permit to Ale a signed statement that he is licensed pursuant to the pmvidons of are Contraclor's
<br /> License law(Chapter B(commentlng,vAOi Section 70W)of Dhvislon 3 of the Businesses and Profseslons Code)or that he Is nempt
<br /> heretrom end the bash for the&Raged sitempibn. Any Violation of Section 1031.5 by any applicant for a permit subjects the eppliunt
<br /> to a ctM presby of not more then five hundred dopers(5500)):
<br /> ❑ 1,waver of to property,or my employees with wages as their ace compensation,will do the work,end the structure h not
<br /> Intended or offered for sale(Section 7044,Businese and Prolewons Code:The contrertofs Uunw Low does not apply to an
<br /> owner of property who bunds or improves thereon,and who does such work himself or through his own employee,provided that
<br /> such Improvements are not Intended or offered for sale. If, however, the bulling or Improvement Is sold within one year of
<br /> completion,the owner.buikferwit have the burden of proving that he did not build or Improve forthe purpose of cele.)
<br /> 13 I,w owner of the property,am exclusively contracting with tcansad contreclan to constnxt the pmjed(Section 7044,Business and
<br /> Proteins Code(BSPC): The Contractors Lrrens i Law,own 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 Contractors License,Law.)
<br /> ❑I ern exempt under Section , B6PC for this reason
<br /> Date: Owren '
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-Insure ore certificates of Workers'Compensation Insurance,or a
<br /> certifled copy thereof(Sedbn 3800,Labor Cada).
<br /> Expintlon Dab L0L11Z Company Ina SU ruoxnlClc Co sA PodNN OF TIA6 wel's
<br /> O Certified copy Is hereby furnished
<br /> )dCerfiMed copy is fled with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed tithe permit is for one hundred dollars(S1 0Q)or less) _
<br /> I certify that in the performance of the work for which this permit Is issued,I shell not employ any person Its my manner w
<br /> as to became subject to the Waken'Compeneston Lowe of California.
<br /> Dab: Appllcent
<br /> NOTICE TO APPLICANT,If,atter making this Certificate of Exemption,you should become wbjed to the WorFere'Compensation
<br /> provisions at the Labor Code,you must furtreNh comply with such provisions or this permit shat be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency ler the performance of the work for which this permt Is issued
<br /> (Section 3097,CrAl Code).
<br /> Lenders Name Q /A,
<br /> Lender Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ 1 hereby caddy that no excavation Me(5) or moa feet In depth into which a person Is required to descend,will be made In
<br /> connection with wok au0ralzed by the permit sand that no building stricture,suffolding,fehewerk or demolition or diamanting
<br /> thereof,wl be mora than Mlrtyalx(38)rest high.(Chapter 3.2,Group 2,Article 2,Section 341,Tile B,Catffomis Administrative
<br /> Code)
<br /> O As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted
<br /> above,unless such pawn hes a permit to do such work from 144 division.
<br /> O Dtv=n of Industrial So"Permit e
<br /> I cemfy that 1 he"mad this spptcatbn and ante that the wove Information Is coned.I agree to ply with all city and county
<br /> ordinances and state awe relating to wet construction sed or sewage system construction,and he ulhodze reprmentatNw of this
<br /> county to enter upon the above-mentioned property for inspection purposes.
<br /> Dab LAI ti f l; Applicant
<br /> F D4 11LENam CONT TOR DECIMATION
<br /> r6se)
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