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JOB ADDRESS
<br />PERMIT
<br />LICENSED CONTRACTORS DECLARATION
<br />I hereby affirm that f am licensed under the provisions of Chapter 9 (commencing with Section 7(1()0) of Division 3 of the Business and Professions Code,
<br />and my license is in full force and effect.
<br />License N
<br />Exp,:Datc _
<br />OWNER -BUILDER DECLARATION
<br />1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Prnfemions Code; Any city or
<br />county which requires a permit to construct, alter, improve, demolish, or 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 Ott provisions of the Contractor's License Law (Chapter 9 (commencing with Section 71}00) of
<br />Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
<br />any applicant for a permit subjects the applicant to a civil penalty of nol mote than five hundred dollars ($500)): Section 703 LS by
<br />0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not imended or offered for sale
<br />jSec, 7044, Business and Professions Code: The Contraclor s License Law docs 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 are not intended or offered for sale. If, however, the building or
<br />improvement is sold within one year of compaction, the owner -builder will have the burden of pteving that he did not build nr improve for the purpose, of
<br />sale)
<br />i ❑ Las owner of the proptxty, am exdusivcly contracting with licensed contractors to construct the project (Sec. 7044, Business and Profession Code: The
<br />Contractor's License Law docs not apply Loan owner of property who builds or improves lhemon, and who contracts for such projects with a contractors)
<br />licensed pursuant to the Contractor's License Law.)
<br />❑ T am exempt under Sec. , B & P.C. for this reason
<br />Dare Owner
<br />WORKERS' COMPENSATION DECLARATION
<br />t I hereby affirm that I have a certificate of consent to self -insure, or a calificate of Workers' Compensation Insurance, or a certified copy thereof (See. 3800,
<br />Lab, Q.
<br />Exp, Date Company
<br />i
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is filed with the County Building Inspection Division
<br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br />(rliis section need not be completed, if the permit is for one hundred dollars ($100) or less)
<br />I certify that in the performance of rhe work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
<br />1 Workers' Compensation Laws of California.
<br />Date Applicant
<br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the
<br />Labor Calc, you muss forthwith comply With such provisions o'r this permit shall be dcemcd revoked-
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there is a construction lending agency foi the performance of the work for which this permit is issued (Sec_ 3097. Civ, Q.
<br />Lender's Namc
<br />Lender's Address
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
<br />01 hereby certify that no excavation rive (5) or more feet in depth into which a person is requited to descend, will be make in connection with work
<br />authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thing -six (30) fcct
<br />high. (Chap. 3.2, Grp 2, An 2, Sec 341, Title 8, C.A.C.),
<br />$Asownb^bttilde+'. 1'wi6 not empioy anyone to doc
<br />work which would regvim a purait,from (lie Division of Industrial Safety, as ogted aboYess 11 unlsuch
<br />m
<br />personfiasapgrtrirtvdo-suctrwkfromthe-ttivisirn----- _.._...--. _
<br />❑ Division of industrial Permit No.
<br />I certify, that I have read this application and state that the above information is tarred, I agree Ia comply with all city and county ordinances and slate laws
<br />relating to well construction and or sewage system construction, and hereby authorize represenNtivcs of this county to enter upon the above-mentioned
<br />property for inspection purposes.
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