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OB ADD
<br />PERNIPf #:
<br />LICENSED CONTRACTORS DECLA RATION
<br />I hereby al,9rm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prrfessions Code,
<br />and my license is in full force and effect.
<br />License #_
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code; Any city or
<br />county which requires a permit to construct, alter, improve, demolish, of repair any structure, prior to its issuance, also requires the applicant for such permit
<br />to file a signed statement that he is licensed pursuant to the provisions of the C'ontractor's License Law (Chapter 9 (commencing with Section 7000) of
<br />Division 3 of the Business and P ofessions Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
<br />any applicant for a permit subjects the applicant 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 intended or offered for sale 3
<br />(Sec 7054, Business and Professions Cade: no Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who
<br />does such work himself or through his own employees, provided that such improvements am not intended or offered for sale. If, however, the building or
<br />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
<br />sale.)
<br />❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the prrject (Sec. 7044, Business and Profession Code: The
<br />Contractor's License Law does no apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) �r
<br />licensed Pursuant to the Contractor's License Law.)
<br />Cl I am exempt under Sec.
<br />. B & P.C. for this reason'
<br />r
<br />Date Owner . 7 . _ .:� . } ,..... - •r ,
<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 thereof (Sec. 3800,
<br />Lab. Q.
<br />Exp. Date Company —_
<br />U Certified copy is hereby furnished
<br />❑ Certified copy is filed with the County Building Inspection Divisicn
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />Obis section need not he completed, if the permit is for one hundred dollars ($100) or less)
<br />I cenify that in the performance of the work for which this porrrdt is issued, I shall not employ any Person i n any manner so as to become subject to he '
<br />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 provisions of the
<br />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 them is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ, Q.
<br />Lender` s Name
<br />Lender's Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br />❑ I hereby certify that no excavation five (5) of more feet in depth into which a person is required to descend, will be make in connection with work
<br />authorized by the permit, and that no building strucruta, scaffolding, falsework, or demolition or dismantling thereof, will be mote than thirty-six (36) feet
<br />high. (Chap. 3.2, Grp 2, An 2, Sec 341, Title g, C.A.C.).
<br />❑ As owner -builder, I .vitt not employ anyone to do work which would require a permit from the Division of Industrial Safety, a_. noted above, unless such
<br />Person has a pemdt hr` do such work from the division.
<br />Division of Industrial Permit No. ,
<br />I certify that I have rend this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws
<br />relating to well construction and or sewage system construction, and hereby authorize representatives of this city to enter upon the above-mntioned property
<br />for inspection purposes.
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