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JOB ADDRESS -z-_ PEIZ 41T
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm, that I ant licensed under the provisions of Chapter 9 (commencing with §cclion 7(X00) of Division 3 of the Businais and Prolessions Code,
<br />rind my license is in full force and effect.
<br />License
<br />OWNER -BUILDER DECLARATION i
<br />1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code; Any city or
<br />county which requires a permit to construct, altet, improve, demolish, or repair tiny structure, prior to its issuance, also requires the applicant for such permit
<br />to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 700)) or
<br />Division 3 of the Business aril Professions Code) or that he is exempt here from and the basis for the alleged exemption. Any violntion of Scetion 7031.5 by
<br />any applicant for a permit subjects flit applicant to a civil penalty of not more than five hundred collars (55(10)):
<br />❑ {, as owner of the property, or my employees will, wages 33 their sole compensation, will do the work, and the structure is not intended or offered for sale
<br />(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
<br />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 a,
<br />imptovement is sold within one year of completion, the owner -bunter will have the burden of proving dial he did not build or improve for the purpose of
<br />sale.
<br />❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sex. 7044, Business and Profession Code: 7hc
<br />Contractor's License Law does not apply to an owner of property who builds or irnprovm thereon, and who contracts for stx h projects wilt a conerartor(s)
<br />licensed pursuant to the Contractor's License Law.)
<br />CI 1 am exempt under Sea B At P.C. for this reason
<br />Date ,_ Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />1 hereby affirm that I have a cenifhcatc of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (See. 3800.
<br />Lab. Q.
<br />Exp. Date Compaay
<br />U Certified copy is hereby lurnished
<br />U Certified copy is filed with the County Building Inspection Division
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(This section need not be completed, if the permit is for one hundred dollars ($100) or less)
<br />I certify that in the performance of the work for which this permit is issued, I stall not employ any person in any miner so as to become subject hh the
<br />Workers' Compensation Laws of California.
<br />Datc_ Appliranl_-_______
<br />h
<br />NO71CC TO APPLICANT: If, after making this Ccniftcate of Excmhptiun, you should beeome subject to the Workers' Comperhsation provisions of file
<br />Labor Code, you must fort0with comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />INN-rhy affirm that there ila construction lending agency for the performance of the work for which this permit is Issued (Sec. 3097, Civ. Q.
<br />Lender's Name 11
<br />Lender's
<br />DIVISION OF INDUSTRIAL SAFOFY PERMIT CERTIFICATION:
<br />U I hereby certify that no excavation five (5) or more feet in depth into which a person is inquired to descend, will be make in connection with work
<br />authorized by the permit, and that no building structure, scaffolding, false,vock, or demolition or dismanding thereof, will be more than ihiry-six (36) feet
<br />high. (Chop. 3.2, Grp 2, An 2, Sec 341, Title 8, C.A.C.). '
<br />C) As owner -builder, I will pot employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such
<br />person has a permit to do such work from the division,
<br />EJ Division of Industrial Permit No.
<br />1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and cranny ordinances and state la,vs
<br />relating to welt construction and or sewage system construction, and hereby authorize reptcsental"s of tris county to enter upon the above-mentioned
<br />property for inspection putpos',
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