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<br /> Jos ADDRESS: I 3 19' L-J k�yL La O 2O R 9 PERMff#:
<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 /> iProfessions Code and my license is in full force and effect.
<br /> License# S g 7 7 3
<br /> Expiration Date 11 3 0 Z O Z Z
<br /> Date (O 1 17 Zo Z I Contractor -rA l CV v fJ TY 0 4.1 i.L/rJ U 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,after,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 /> 0 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 /> 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 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 /> 7EC
<br /> tration Date17-/31/207-1 Company CC) m QCiVS,t377(W �A1,5,A1,5, �e-Arl�
<br /> t'J ertified copy is hereby furnished
<br /> O Certified copy is filed with the Environmental Health Department
<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 r
<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: 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). 1,/
<br /> Lender's Name IJIA
<br /> Lender's Address
<br /> 0/ 1
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> L7 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 3.2,Group 2,Article 2, Section 341,Title 8,California Administrative
<br /> Code).
<br /> O 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 /> O DNIs"of Industrial 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 t e above-mentioned property for inspection purposes.
<br /> Date �0 I 17 �20 yl Applicant -7-yt CO J rJ 'I?' p JLf(,l."(r / '
<br /> T
<br /> EHD 4302-007 LICENSED CONTRACTORS DECLARATION
<br /> 626-09
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