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JOB ADDRESS: _ ! (V Z 11 5A Gc_ti, T-ri C/,(L,C L te-
<br />PERNti #:
<br />LICENSED CONTRACTORS DECLARATION
<br />1 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 # 5 LI! 7 7 3 7 Expiration Date r f So 2 0 2:'Z
<br />Date (0/17 % ZD 2 I _ Contractor 7 l C,00 00 rr C
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractors 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 Contractors
<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 />❑ 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 7D44, 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 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 Contractor's License Law.)
<br />❑ 1 am exempt under Section , B8PC for this reason
<br />Date:- —
<br />Awner
<br />WORKERS' COMPENSATION DECLARATION
<br />I hereby affirm that I have a certificate of consent to self4risure or a certificate of Workers' Compensation Insurance, or a certified copy
<br />thereof (Section 3800, Labor Code).
<br />EXfration Date Z 31 ZD Z 1 Company F u ^)D CD Yn PLAJ-S-,477 d/ / Afs- r�gA/Qr
<br />f9 Certified copy is hereby fumished
<br />❑ 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 Ig100; 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 Cafrfomia.
<br />Date:
<br />Applicant
<br />NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you should become subject to the Worker;
<br />provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br />Compensation
<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). 1l/
<br />Lender's Name IJIA
<br />Lenders Address
<br />0/1
<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, talsework, 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 />❑ 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 />❑ Division of Industrial Safety Permit #
<br />I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county
<br />ordinances and state laws relating to well construction and or sewage system constriction, and hereby authorize representatives of this
<br />county to enter upon t e above-mentioned property for inspection purposes.
<br />Date a 117 2O 2-` Applicant -' t CO 0,
<br />TY p ,B -J ur.J !t�
<br />EHD 43-02-007
<br />6.2" LICENSED CONTRACTORS DECLARATION
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