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Joe ADDRESS:'ISCI SACC- j4tLI4WI%,y, L-C`C'<0f_o" PERMIT N:
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<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby aMom that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is In full force and effect.
<br /> License# �IO-21o3K Expiration Date 31 3013
<br /> Data 7L�3-O L.2._ Contractor k-G?k%I TN QZ-9- 00 tum vis T'
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractors License Law for the following mason(Section 7031.5,Business and Professions
<br /> Code: Any city or county which requires a penult to Construct,alter, Improve,demolish,or repair any stmdure,prior to Xe Issuance,
<br /> also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractors
<br /> License Law(Chapter 9(commencing,wilh Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> 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 sale Compensation, will do the work, and the structum Is not
<br /> Intended or offered for sale(Section 7044, Business and Professions Code: The contractors License Law does not apply to an
<br /> owner or property who builds or Improves thereon,and who does such work himself or through his awn 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 /> Comp!ation,the ow.or-builder will have the burden of proving that he did not build or Improve for the purpose of Sale.)
<br /> O I,as owner of the property,am exclusively Contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(BdPC): The Contractors 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 Contractors License Law.)
<br /> O 1 am exempt under Section , BBPC 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 Workere'Compensation Insurance,or a
<br /> certified copy thereof(Section 3800,Labor Code).
<br /> Expiration Date tL LIJ 20 1Z Company Ca�
<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 /> Mis section need not be completed if the permit 11 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
<br /> as to become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT: ff, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br /> provisions of the Labor Code,you must forthwith Comply with such provisions or this permit shall be deemed invoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
<br /> (Section 3097,Civil Code).
<br /> Lenders Name IJ 14,
<br /> Lender Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> O 1 hereby certify that no excavation five (5) or 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 demolition or dismantling
<br /> thereof,will be more than thirty-six(36)feel 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 Safely,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> O Division of Industrial Safety Permit N /
<br /> I cartify that I have read this application and state that the above information is correct. I agree to c (nply with all city and County
<br /> ordinances and state lawn relating to well construction and or sewage system construpioq end he uthor¢e representatives of this
<br /> County to enter upon the above+nentioned property for inspection purposes.
<br /> Date 1 LI�Q'Z. Applicant
<br /> EMO 4307 LICENSED CONTRACTOR DECIARATON
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