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.IOBAMRM:_ ZeSZ/ O/r`k(I /��iL PER1er* LICENSED CONTRACTORS DECLARATION I hereby atfnn that I am licensed under the provW— of Chapter 9 (commex,ctny with Section 7000) of L)Msion 3 of the BUskI and PfOfk%bns Code and my license, is 's, fun force and effect. License 5/ t } Expoation Date 00 ` 2.21 Date "7- 3 - ZG Zi Contractor Nr OWNER-BURMER DECLARATION I hereby affirm that I am —Pt fran the Contractors License Law for the 1Piow'vtg reason (Settior 7031.5, Business and Professions also reQ Arty city the r county which for sum permit pet to construct aper. improve, demolish, or repair any sfnxhae, prior to its issuance, License Law (he p pili s ( ch P� to file a signed staternent that he is licensed prxsuant to the Provisions of the Contractors cammanong with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt fi to � t>�ra than ve and the basis on for the alkged—amptiw,. Any vio6fiof Ssdiw, 70al-5 by am' ,pPr,�r,t for a mit the app6�ry Penalty of not mohundred dollars ($5W))_ per O 1. as owner of the Property, or my employees Wjth mages as their sole i<,lended o offered for sale {Section 7044, B,ustr,ess and Cornpemsalion, w� do the world and the sU,rctrue is not Downer of property who builds a " Professions Code: The contractors License Law does riot apply to an such _ trr,proves thereon. and who does such work himself Of through his own employees. Provided that arQrovtir>ergs are not brlendod or offered for sale 1f, however, the txricfm9 or improvement is sold withir, one year of completion, the owner-buWder vM have the burden of Proving that he did not build Or improve for the purpose of sale.) 0 1, as owner of ttte Property, am exdraivey cont acting with ficensed contractors to construct the PMW (Section 7044, Business and Professio ertn Code (B&PC)_ The Contractors License Law does not apPIy to an owner Of Property who buds ior improves hereon, and who c*Ucts for such Projects wfth a Contiactnr(s) hissed Ptast>ant to the Contractors L"se Law_) ❑ 1 am exempt under Section . B&PC for Utas reason Dale- Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a cu finite of consent to sell-irsure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Semon 3800, Labor Code) Expiration Date Company ❑ Certified Copy is hereby furnished E3 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE fThis section need not be cormPteeod if the Permit is for one hundred dollars ($100) or less) I Certify that r1 the perfom Ice of the work for which this Permit is issued, I strati not em b become subject to the Workers' Compensation Laws of Califomra P Y arty Person in any manner so as to Data: Applicant NOTICE TO APPLICANT_ U, atter making this Certificate of Provisions of the Labor Code, you must farur*-dh such Provisions 1s ou should become subject to the Workers' Compensation mith such Provisions or this permit shall be deemed revoked_ CONSTRUCTION LENDING AGENCY I hereby affrrn ttr-d there is a Construction lending agency for the performance of the work Col Code). for which tis Permit is issued (Section 3097, Lender's Name Lender's Address DIMION OF INDUSTRIAL 5AFETY PERMIT CERTIFICATION connectio❑ 1 hereby certify that no exca 24on fivorized by u-j e (s) or more reef in depth into nrtnlCh a person is rernlQed ib descend wet be rrsad� thereof, tN0 Die rel Ulawork n a k�C and that no building stnjetu e. scatfoldrig, l tC or dernaBion or dismanmvxj Code). d' DC )feet h5t' (Chapter 3-Z Group 2 Article 2. Section 341, Title 8. California Administrative E3 As mime-builder, t -A not —Ploy —'Ywm b do work which Would require a permit from the Divsion of Indratrial Safety. is rwtea above, --OSS such Person has a permit to do such work from the dtvsiat O Dtvision of Industrial Safety Permit it I certify that I have read this aPPkabon and State that the above information is correct, 1 agree to comply with all city and co r,ty O"'Or 1ces enter upand on bum relating to wei duction and Pr sewaW Symon consbucbM and hereby auffxm a representatives of ass Property for aspeciion purposes_ Date Applicant EM 43.02-001 Gafo9 ISDCONTPACTpnSown Toon