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LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed Under the proUisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my 'Tele is in "II force and effec License # Cont 0 NER-BUILDER DECLARATION Date t. Li 5 Expiration Date ae/ AI Aii;deibe eaffel or JOB ADDRESS: PERMIT #: tion 7031.5, Business and Professions air any structure, prior to its issuance, nt to the provisions of the Contractor's rofessions Code) or that he is exempt ant for a permit subjects the applicant exclusively he Contracto 's rojects with !co I hereby affirm that I am exempt Code: Any city or county which also requires the applicant for s License Law (Chapter 9 (comm herefrom and the basis for the to a civil penalty of not more tha 0 I, as owner of the property, intended or offered for sale owner of property who build such improvements are not completion, the owner-builde 0 I, as owner of the property, a Professions Code (B&PC): and who constructs for such ac or's License Law for the following reason (Se t to construct, alter, improve, demolish, or re a signed statement that he is licensed pursue n 7000) of Division 3 of the Business and Any violation of Section 7031.5 by any appli ars ($500)): with wages as their sole compensation, wil do the work, and the structure is not siness and Professions Code: The contractor's License Law does not apply to an eon, and who does such work himself or thrOugh his own employees, provided that ed for sale. If, however, the building or improvement is sold within one year of den of proving that he did not build or improve for the purpose of sale.) racting with licensed contractors to construct the project (Section 7044, Business and icense Law does not apply to an owner of property who builds or improves hereon, tractor(s) licensed pursuant to the Contractor's License Law.) om the Con requires a p ch permit to ncing with S eged exemp five hundred r my emplo Section 704 or improves intended or will have the WO RS' COMPENSATION DECLARATION thereof (Section 3800, Labor Cobe) I hereby affirm that I have a certeicate of consnt o self-insure or a certificate of Workers' Compensation Insurance, or a certified copy Expiration Date (XII a 12 co pany e EGAL Cr) O Certified copy is hereby furniJed ‘jd Certified copy is filed with the Environment alth Department M TION FROM WORKERS' COMPENSATION INSURANCE CERTIFICTE OF EX (This section need not be comol I ted if the per it is for one hundred dollars ($100) or less) f the work fit ich this permit is issued, I shall not employ an I certify that in the performance Compensatio L ws of California. become subject to the Workers' person in any manner so as to 0 I am exempt under Section Date: B&PC for this reason er Date: Ap licant NOTICE TO APPLICANT: If, alUtI er making t provisions of the Labor Code, you must forth I hereby affirm that there is a construction len Civil Code). Lender's Name Lender's Address is ertificate of Exemption, you should become th omply with such provisions or this permit shal subject to the Workers' Compensation be deemed revoked. NSTRUCTION LENDING AGENCY in • agency for the performance of the work for which this permit is issued (Section 3097, DIVISION 0 — I DUSTRIAL SAFETY PERMIT CERTIFICATION 0 I hereby certify that no excavation five ( 3) connection with work authonzed by the p r more feet in depth into which a person i it, and that no building structure, scaffolding, required to descend, will be made in falsework, or demolition or dismantling