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JON ADOREss: PERRI T LICENSED CONTRACTORS DECLARATION I hereby affirm that I ern Homed under the o,mislors of Chapter 9 (commencIng with Seder/ 703(I) of Division 3 of the Business and Professions Cate ace try license is in full 'circa arid effect. License 10 1-0144 5 Eypiration Date q/3o/z z. Date 6/16/2021 Contractor rev Dr41v`k-, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt ftom the Contractor's Licerse Law for tee following reason (Section 7031 5. Business and Professions Coda: My city or =linty which requires a pent to &instruct alter Improve. demolIsh, or repair any structure, prior to its Istuance, also requires the applicart for such permit to file a signed statement that he Is licensed pursuam to the prce4eors of the Cortreacres License Law (Chirpier 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. Ary violation of Sectlen 7031.5 try any applicant for a peerlt subjects the applicant to a civil penally of not more than five hundred dollare ($530))* 1:1 I, as owner o' the property, or my emptcyees with wages as their sole cornpereation, will do the work, and the structure is not intern:We or offered for sale (Sedior 7044, Business one Professions Code: The contractces License Law does not apply to an owner of property who builds cr Improves thereon ard 4io does such work eimsegf or throug1 Ns awn employees. provided that such improvements are not Intended or offered for sale, if, however; the building or improvement Is sold within one year of corrofeticn, 3e autner-burkler will have the birder of proving that ne did not build or Improve for the purpose elute.) I, as owner of the property, are exclusively craetracting with iormsed contractors to construct the project (Section 7044, Business and Profesetne Cade (88PC); The Contractors Licrerse Law does not apply to an owner of prooerty who builds or improves hereee, end whe constructs for such proects with a cont.-adage licensed ;truant to the Contractor's License Law.) I am exempt under Section Iii&PC for [hie reason Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of cornoni to self-insure n a eetificete err Vsrf1e55 Compensation Insurance. ore celitied copy thereof (Sealer 3600, Labor Coca). Expiration Date Company CI Codified copy a hereby furnished IV(Ceillfied oar:1y Is ft ed win he Envrinme.eisi Hester Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Mies secticn need net fleoop1ele,ç f the permit Is For one hurered dpilare 1$10N) V- fee*/ I certify Mat In the performance of the work for which ties perrnit a issarec,ishall rot employ any person In aly Mannerso as to oecome subject to the Wierkere Cempoesation Laws of California Date: Applicant NOTICE TO APPLICANT.. lf, alter mareng this Certificate of Exemption, you should become subject to the Workers' Comoensei. err previsions of the Labor Code, you must forthwith comply with scch provisions or this permit shall be deemed renewed CONSTRUCTION LENDING AGENCY I hereby affirm that there is a oenstruceon lending agency for the performance of the weir for which tnis permit is Issued (Section 3097, Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION XI hereby certify that no excavation IThve (6) or riltre feet in depth into which e person Is required to deemed, will be mace in connection with work authonzed by the permit, and that no butane strueture, scaffolding, falsework, or demolition or dismanting thereof, will be more than thirty-six (36) fese high. (Chapter 32, Group 2, Article 2, Section 141. This 8, California Administrative Code). 0 As owneebullder I will not employ anyone to do work which would require a pa-mil from the Division of Molise-la' Safely, as noted abode, unless such parser has a permit to do such work from the diviebn. O Division of Industrial Safety Permit N I certify that I have mac this application and rate that the stove Information Is cared. I neree to comply will all city mid county endinar ass and state lavas relating to well construction and or sewage system mesh- or, aed hereby eV/mixt representatives of this county to enter upon the above-meetioned property for InspeotIon purposes. Date 6/16/2021 Applicant Jake Wilson E14:, 42-0242/ LICENSED CONTRACTCRS DECLARATICI. 11,26.09