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JOBADDREss: I'll- 10 \ C_� p1_R'itJ _�_ IZA Pcoui . LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed un r the provisions of Chapter 9 (commencing with Section 7000) of Divi ion 3 of th Business and Professions Code and li i full force and effect License (� 1 xpi(f tion Date Date Contractor G1 / I � L 1 ( v l /f lLt OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031.5, Business and Professions Coda: Any city or 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 to file a signed statement that he is licensed pursuant to the provisions of the issuance, 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 bests for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do Ire wort, and the structure Is not inlanded or offered for sale (Section 7044, Business and Professions Code: The oontractoes 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 he 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): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contactor(s) licensed pursuant to the Contractors License Law.) ❑ 1 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 -insure or a certih to of Worker 'Compensation Insurance, or a certified copy thereof ( ecfi n 3800, Labor Code). �; Expiration Date `D Company ❑ Certified copy is hereby furnished Y11 ertified copy is filed with the Environmental Health Department CERTIFICATE OF EX This section need not be completed if ti I certify that in the performance of thew as to become subject to the Workers' C( Date: NOTICE TO APPLICANT: If, after making provisions of the Labor Code, you must fortt I hereby affirm that there Is a constructi� (Section 3097, Civil Code). Lender's Name Lender' Address NMWallaceKuhl so S A a 3 C C I A T e 6 CORPORATE OFFICE tion 30SO Industrial. Blvd. West Sacramento, CA 95691 916.372.1434 fax 916.372.2565 J DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, wit be made in connection with work authorized by the permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, Califomia Administrative Code). `` 0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of dustriai a4, as re.e above, unless such person has a permit to do such work from the division. ❑ Division of Industrial Safety Permit M I certify that I have read this application and state that the above information Is correct I agree co ply wth all c and co2ty ordinances a d state laws relating to well construction and or sewage system cons coon, and 1h au rize represen tives of this county to r upon h bo e -mentioned property for inspection purposes. r I Date Applicant i EHD 4307 101597 l SED CONTR OR DECLARATION