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JOB ADDRESS: 3 0 If& f) A-V e Y /L I t/ c
<br />PERMIT #:
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
<br />Professions Code and my license is in full force and effect.
<br />License # S k 7 7 3
<br />Expiration Date � � 3 D Z4 ZZ„
<br />Date 67 j i 7 j Zo 2 j Contractor 7-121 Cou 7--t' 0.,L I c.L./rJU N C,
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions
<br />Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance,
<br />also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's
<br />License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt
<br />herefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant
<br />to a civil penalty of not more than five hundred dollars ($500)):
<br />❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br />Intended or offered for sale (Section 7044, Business and Professions Code: The contractors License Law does not apply to an
<br />owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that
<br />such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br />completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and
<br />Professions Code (B&PC): The Contractors License Law does not apply to an owner of property who builds or improves hereon,
<br />and who constructs for such projects with a contractor(s) licensed pursuant to the Contractors License Law.)
<br />❑ 1 am exempt under Section , B&PC for this reason
<br />Date: Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy
<br />thereof (Section 3800, Labor Code).
<br />E77EC
<br />1ration Date Z 31 Z0 Z 1 Company S7'A o E F -J-0-J-0G0 m PL A/5 4-ri aJJ % N
<br />ertfiied copy is hereby furnished
<br />❑ Certified copy is filed with the Environmental Health Department
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />LThis section need not be completed K the permit is for one hundred dollars ($100i or less 1
<br />1 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
<br />become subject to the Workers' Compensation Laws of California.
<br />Date:
<br />Applicant
<br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation
<br />provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097,
<br />Civil Code).
<br />Lender's Name —PIA A
<br />Lendets Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />0/1 hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in
<br />connection with work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling
<br />thereof, will be more than thirty-six (36) feel high, (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br />Code).
<br />❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted
<br />above, unless such person has a permit to do such work from the division.
<br />E3 Dfv Ww of Indusbtal Safety Permit # _
<br />' 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county
<br />ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon_
<br />a above-mentioned property for inspection purposes.
<br />Data �D 17 2 0 Z j Applicant -7711,1, CO J M1/ �7'' p (1.J u !.J U, f
<br />EHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br />6-26-09
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