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JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business, and Professions Cade, and my license is in full force and effect. License 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 provisians of the Contractor's License Law (Chapter 9 (eumttrncing with Section 70170) 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 the•. 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 offered for cafe (Sec. 7044, Business and Professions Code: The Contractor's License 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 sale. If, however, the building or improvement 1s sold within one year of compiwon, the owner -builder will have the burden of proving that he did not Wild or improve for the purymsu of sale.) Ell, 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 coniracim(s) licensed pursuant to the Contractor's License Law.) M L am exempt under Sec. _ - 3 & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a cottifcate of consent to self -insure, or n cert fieate of Workers' Compensation Insurance. or a cenifned copy thereof (Sec. 3800. Lab. Q. Exp. Date Company M Coni fiat copy is hereby furnished 0 Ccrt f ed copy is fled with the County Building Inspection Division CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section aced not W completed, if the permit is for one hurdred dollars ($100) 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 the Workers' Compensation Laws of California. Date NOTICE TO APPLICANT: 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 doomed revoked. CONSTRUCTION LENDING AGENCY I hereby affurm that there is a conatnretion leading agency foi the performance of the work for which this permit is issued (Sec. 3097, Civ, Q. Lender's Namc Lender's DIVISION OF INDUSTRIAL SAFEW PERMIT CERTIFICATION: Cl I hereby ccnify 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 demolition or dismantling thereof, will be mere than thirty-six (36) feet high. (Chap, 3.% Grp 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 parson has a permit to do such work from the division. 0 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 concoction andor sewage system construction, and hereby authorize representatives of this county tr die above-n=tioned property for inspection purnoses,