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FJos.A�ORSIC
<br /> g'� J 1?S +fir �-}li to w Awn �d' �G tf9Fu1� PERMIT M:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> rm that 1 am floating under IM provisions of Chapter g(commencing withSedbn 7000)of Olvlslon 3 or Ilia Buslnsu and
<br /> Code and my license O in futl form and select
<br /> License p. go-2,03K Expiration Oda 4S3lZ --c j3
<br /> Dais_14;Q-7-0 12_ Contractor lC G PRCL't 01;{C Lb rz(f V M/tic 'M# T'
<br /> OWNER-BUILDER DECLARATION
<br /> I hemby affiant thal Ism exempt from the Ccnlractors License Law for The fosowvng rasion(Section 7031.5,Bu lness and I mroomims
<br /> Code: My cRy or county which requires a penult to construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,
<br /> Ilia mqulres the applicant for such permit to file s signed statement that he Is licensed pursuant to the provislons of the Con"cla's
<br /> License Law(Chapter O(commsDNrig,ydth Section 7000)of Division 3 of rise Ousinass and Professions Code)or that he la exempt
<br /> herefrom said the basis to(the olreged examption, Any vlorallon of Sectio 7031.5 by any applicant for a permit subjects the appMaril
<br /> to a civil pansttq of not mon man Rva hundred dollen($500q:
<br /> ❑1, as owner of The property,or my employees wlln"goo as their sole compensation, wall do me work and the structure a not
<br /> Intended or offend foe into(Section 7044, Bnalneae And Profeastona Code' The contractors License Law does not apply to an
<br /> ovmer of property who builds of Improves dmmon,and who dos*such work taersalf or auough his own employees,provided mat
<br /> such Improvements am not Intended or of@red fa sale. If, however, the building or Improvement Is sold within one year of
<br /> cornrWion,the cwnar-builder will have the burden of proving that he did not bund w knprove for the purpose of seta.)
<br /> ❑I,As owner of UN property,am oxduslvely contracting with eased conliect rs to conatmd the project(Section 7044,Duelness and
<br /> Professions Code(BdPC)- The Contractors Llcenso Law does not apply to an owner of property who builds or Improves hereon,
<br /> and who constlucla for such projects with a contmdor(s)licensed pursuant to the Contractors License Low.)
<br /> O I am exempt under Section BSPC for this reason
<br /> Date: Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm That 1 have a cen)ficate of consent to so If- or a certificate of Workers'Compensation Insurance,or a
<br /> certified copy thereof(Section 3004 Labor Cade),
<br /> Expinllon Date- l 20 12company S4 e-5-Gtr NPsc'\o l-�r>t 1 t�11. C_o
<br /> O Certified copy Is hereby furnished -
<br /> XCertlfied copy Is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This saclion need not be Completed If thepermit Is for one hundred do0am ISM)or lose)
<br /> I certify that In the performance of the work for which Ihis permit Is issued,I shell not employ any person In any manner so -
<br /> as to become ecoe subject to the Workers'Compensation Laws of California,
<br /> Date: _,_,_ Applicant
<br /> NOTICE TOAPPLICANT: If. after making this Cenifula of Exemption, you should become subject to the Workers'Compensation
<br /> pwvislcm of the Labor Code,you must forthwith comply with such proviolons or this permit shall be deemed invoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby athrm that them Is a construction lending agency for the performance of the work for which this permit is issued
<br /> (Sectfcn 3D97,Civil Code),
<br /> Lenders Name IJ l A,
<br /> Lender Addros l
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> O 1 hereby certify that no exuvalion five (5) ser mom 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 demoation or dismantling
<br /> thereof,will be more man mlrly-s4(3a) feel high. (Chapter 3.2,Group 2,Article 2, Section 341,Trla e, California Admarlstrs Uwe
<br /> Codes
<br /> 0 As owner-builder,1 wit not employ anyone to do work which would require a permit from the Dlvteion of Industrial Safely.as noted
<br /> above,unless such person has a permll to do such work from(he division,
<br /> O Division of Induabtd Safety Permit e
<br /> I certify that I have mad this application and state mal the above Information O correct I agree to ply with all city and county
<br /> ordinances and state Owe relating to"]I
<br /> construction and or sewage system construction,and her rdnodze representatives of this
<br /> county to enter coo
<br /> lnI the abovemenkoned property for Inspection purposes.
<br /> Date �.Z-f`?�t�- Applicant
<br /> Flip 4147 LICENSED CoOil BTan 0ECtARATICB
<br /> 1NSe7
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