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FJoe ADDRESS: 31 1 d
<br /> (41165T, M,o-2c-ri L-,*N
<br /> PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 8(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 7 Expiration Date 11 I- Z301 Z O Z Z
<br /> Data rl 7 Za Z 1 Contractor _rA 1 Cd u r.l T1' Q 2l LL J rJ& / J 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 qty or county which requires a permit to construct,atter,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 j
<br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt j
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant i
<br /> to a civil penalty of not more than five hundred dollars($500)):
<br /> ❑ I,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 contractor's 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 /> comp(etion,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 Contractor's 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 Contractor's 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 /> ZE iration Date Z 31 ZO Z I Company :57-10°'� F v^/� C-0 m PLn/S T7 t:fJ
<br /> I9 Certified copy is hereby furnished
<br /> ❑Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> IThis section need not be completed if the permit is for one hundred dollars($100i or less,
<br /> 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
<br /> become subject to the Workers'Compensation Laws of California.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT:lf, 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 —IJA
<br /> Lender's Address
<br /> I
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> i D I 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)feet high.(Chapter 3-2Group 2,Article 2,Section 341,Title 8,Califomia Administrative
<br /> Code).
<br /> ❑ As owner-builder,1 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 /> ❑Division of Industrial Safety Permit# _
<br /> 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
<br /> iordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this
<br /> county to enter,upon t e above-mentioned propfor inspection purposes.
<br /> Date 17 , erty 2,0 Z f Applicant -T-a-' CO J,v Tr' p /�.�L 4,1AJ(�. JAA(�
<br /> EHD 43-02-007
<br /> 6-2649 LICENSED CONTRACTORS DECLARATION
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