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c JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 70DO)of Division 3 of the Business,and Profrssiom Code, and my license is in full force and effect. License lfaxp.:Datc Dale COmracior OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.70315.Business and Professions Code; Any city or county which requires a permit io construct,alter,improve,demolish,or repair any structure,prior to its issuance.also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(eumnrncing with Section 7060)of Division 3 ofthe Business and Prufassions Code)or that he is exempt herefrom and the basis for the alleged excmpdon. Any violation of Section 7n31.5 by any applicant for a permit subjects tht•.applicant to a civil penalty of not more than five hundred dollars Q 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offend for sale (Sec.7044,Business and Professions Code:The Contractor's Licenso Law docs not apply to an owner of property who Wilds or improves thereon.and who does such work himself or through his own employees,provided that such improvements are not intended or offered for salm If,however,the building or improvement is sold within one year of compi lion,the owner-builder will have the burden of proving that he did not Wild or improve for the puryrose of sale.) 0[,as owner of the propeny,am exclusively contracting with licensed contractors to construct the project(Sec.7044•Business and Profession Code:The Contractor's License Law dots not apply to an owner of propeny who builds or improves thereon,and who contracts for such projects with a coniractar(s) licensed pursuant to the Contractor's License Law.) M f am exempt under Sec._ 3&P.C.for this reason Date Owner WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a cptifcate of consent to self-insure,or n cert fieate of Workers'Compensation Insurance,or a cenifred copy thereof(Sec.3800. Lab.Q. Exp.Date Company _ 0 Coni fiod copy is hereby furnished 0 Cert f ed copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section aced not be completed,if the permit is for one hurdred dollars($!00)or less) - 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 become subject to ttc Workers'Compensation Laws of California. Date Applicant NOTICE TO APPLICANT:If,after malting this Certificate of exemption,you should became subject to the Workers'Comperimulon provisions of the Labor Cala you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a conatnretion leading agency for the performance of the work for which this pomilt is issued(Sec.3097,Civ,Q. Lender's Nems, Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: Cl I hereby cenify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in connection with work authorized by the permit,and that no building structure•scaffolding,falsework,or demolifion or dismantling thereof,will be mere than thirty-six(36)feet high. (Chap,3.%Cirp 2,Art 2,Sec 341.Title 8,C.A.C.). 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as aced above,unless such person has a permit to do such work from the division. ❑Division of Industrial Permit No. I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances end state laws relating to weil construction andor sewage system construction,and herby outhodw representatives of this county tr ere above-n=tionod property for inspection pumoses. Date_ Applicant i