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JOB ADDRESS: PERMIT ; LICENSED CONTRACTORS DECLARATION hereby affirm that l am licensed under the provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Prefessions Code. and my license is in full forte and effect. License it E.sp.:Datc Date Contractor OWNER-BUILDER DECLARATION hereby affirm that I urn exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code; Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires tire applicant for such permit to Bien signed statement that he is licensed pursuant to the provisions of the C.onemetor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant ton civil penalty of not more than five hundred dollars ($5001): 131, 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 offered for sale (sec. 7044, BusinesS and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intendal or offered for sale. If, however, the building or improvement is sold within one year of compia ion, the owncr-builder will have the burden of proving that he did not build or improve for the purpose of sale.) 0 I, as owner of the propeny. am exclusively contracting with lirarised contractors to COnStrUCI the project (Sec. 7044, Business and Profession Coele• The Contractor's License Law does not apply to an owner of property who builds or improves Macon, and who contracts for such projects with a coniructiu(s) licensed pursuant to the Contractor's License Law.) DI tun exempt under Sec. 3 & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby aMrm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation Insurance. or it certified copy thereof (Scc 3800. Lab. C). Esp. Date Company 0 Certified copy is hereby furnished 0 Certified copy is filed with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed, if the permit is for one hundred dollars ($100) or less) I certify that in the performance of the work for which this permit is issued, I shall not employ arty person in any manner so as to become sahjer.1 to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICAN'T: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY i hereby affirm that there is a construction leading agency for the performance of the work for which this permit is issued (Sec. 3097. Clv. C). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAlkiT'z' PERMIT CERTIFICATION: t hereby certify 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. falsewark, or demolition or dismantling thereof, will be mere than thiny.six (36) feet Nigh. (Chap. 3.2, Grp 2, Art 2, Sec 341. Title 8, C.A.C.). CI As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safely, as noted above, unless such person has a permit to do such work from the division. Ci 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 IO Well Construction and or sewage system construction, and hereby authorize representatives of this county to e-• the above-mentioned property for inspection pumoses. Date_ Applicant