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Joit ADDRESS: PEttAIIT #: LICENSED CONTRACTORS DECLARATION I h—by affirm that I arrt licensed under the provisions of Chapter 9 (-cormnancins with Section 7000) of Division 3 .of the and Professions Code and my license is in full force and effect. License 9— Expiration Date Contractor OWNER -BUILDER DECLARATION I hereby affirm that i am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busines and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, p 'or to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions f the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or t he is exempt here&om and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit su jects the applicant to a civil penalty ofnot 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 's 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 improvements are 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 be did not build or improve for the purpose of sale.) ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code (B&PC); T'he Contractors License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License law.) 13 I am exempt under Section , B&PC for this reason Date: Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -instar, or a certificate of Workers' Compensation hzvurati-,e, or a copy thereof (Section 3800, Labor Code). Expiration Date Company 13 Certified copy is bareby furnished 13 Certified copy is tiled with the Environmental Health Department CERTIFICATE O F EXIMPT1 ON FROM WORKERS' COhIPENSA't'ION Ii'IiSUi2ANCE f his section need not be completed if the permit is for one hundred dollars ($100) or less) I certify that in the performance of the work for which this permit is issued, I shali not employ any person in any manner so as to becorm subject to the Workers' Compensation Laws of California. Date- Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should becornc subject to the We Compensation 'provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed rev CONSTRUCT(ON LENDING AGENCY I hereby affirm that there is a constriction lending agency for the performance of the work for which this permit is issued 3097, Civil Code). Lender's N Lender' Address DIVISION OF INDUS'l-RIA1, SATF-n- 1'ER IIT CERTICA77O Cl I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be de in connection with work authorized by the pemtit, and that no building structure, scaffolding, falseworlk or demolition or ' thereof, will be mora than thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California A live Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Sa ty, as noted above, unless such person has a permit to do such work from the division. ❑ Division of Industrial Safety Permit # I certiFf that I have read this application and state that the above information is correct. I agree to comply with all city.andounty ordin inces and state laws relating to well construction and or sewage system construction, and hereby authorize representatives bf this county to enter upon the above-mentioned property for inspection purposes. 13+1e Applicant EHD 43-02.007 MASTER water well Pcrnm Contractor Declhnction 12/5/2002