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JOB ADDRESS: PERMIT #: LICENSED CONTRACTORS DECLARATION I hereby effirm that! am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License # Date Expiration Date Contractor OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section .7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires die applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for the alleged exenrption. Any violation of Section 7031.5 by any anplicant for a permit subjects the applicant to a civil penalty or not more than five hundred dollars ($500)): 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such iminovements arc not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) 1, as owner of the property, an exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code (B&PC): The Contractor's License Law does not apply to ar, owner of property who builds or improves hereon, and who consiructs for such projects with u contractor(s) licensed pursuant to the Contractor's License Law.) O 1am exempt under Section , D&PC for this reason Date: Owner WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Labor Code). Expiration Date Company 0 Certified copy is hereby fumisiaecl 0 Certified copy is filed with the Environmental Health Department CER tIE ICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if theoperrnit is for cine hundred dollars ($100) or less) 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 become subject to the Workers' Compensation Laws of California. Date: Applicant NOTICE '1'0 APPLICANT: If, after roalcing this Certificate of Exemption, you should become subject to the Workers' Compensation provision!, of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perfomiance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender' Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION 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 ga I • Iv, lel. err. elesirl I II tliel INT ri enr111 nrlin.,