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<br />JOB ADDRESS: PERMIT #
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<br />LICENSED CONTRACTORS,DECLARATION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business
<br />and Professions Code and my license is in full force and effect
<br />License # - Expiraiion'Date
<br />Date
<br />Contractor
<br />• `v~°i•�`1� - `rte
<br />OWNER -BUILDER DECLARATION
<br />I .hereby affirm that I am exempt from the Contractor's License Law for the following reason -(Section 7031.5, Business and
<br />Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to
<br />its issuance, also requires the applicant for such permit. to file a signed statement that he is licensed pursuant to the provisions of the
<br />Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he
<br />is exempt herefrom and the basis for the alleged exemption'. Any violation of Section 7031.5 by any applicant for a permit subjects
<br />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
<br />intended or offered for sale (Section 7044, Business and Professions Code: The contractor's License Law does.not apply to an
<br />owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that
<br />such improvements are not intended or offered for sale. If,. however, the building or improvement is sold within one year of
<br />completion, the owner -builder will have the burden ofproving that he did not build or improve for the purpose of sale.)
<br />❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br />and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br />hereon, and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
<br />❑ I am exempt under Section B&PC for this reason
<br />Date: Owner
<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
<br />copy thereof (Section 3800, Labor Code).
<br />Expiration Date Company 6
<br />❑ Certified copy is hereby furnished
<br />❑ Certified copy is filed with the Environmental Health Department .
<br />1 _CERTIFICATE OF EXEMPTION FRONI WORKERS' COMPENSATION INSURANCE
<br />I certify that the performance of the work for which this permit. is issued, I shall not employ any person in any manner so as to
<br />become suubj ct to the Workers' Compensation Law of-Cahfornia.
<br />Date:
<br />Applicant
<br />APPLICANT: If, after making this Certificate of Exemption, yo sho.W,
<br />provisions of the Labor Code, you must forthwith comply with such provisions or
<br />CONSTRUCTION
<br />I herebyAu that there is a construction lending agency for the
<br />3097, Civil Code). '
<br />AGENCY
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<br />become subject to the Workers'
<br />i?Permil shall be deemed revoked,
<br />for which this permit is issued
<br />C}`
<br />DIVISION OF INDUSTRIAL SAFETYERMIT CERTICATION
<br />❑ I hereby certify that no excavation five (5) or more feet'in.depth into which a person is required to�lescerid, will be made in
<br />connection with work authorized by the permit, and that no building structure, scaffolding, falsewo-< or demolition or dismantling
<br />thereof; will•be•morethan'thiity-six•(36)•feet'high-(Chapter-3`2, Groupl, Artible`2,-Sec
<br />- Code). otr341"Title'8; California Administrative
<br />t
<br />❑ As'owner-builder, I will not employ anyone to do work which would,require a permit-froftt;the. Division of Industrial Safety, as
<br />noted above, unless such person has a permit to do such wor) xrom the division. t'
<br />❑ Division of Industrial Safety Permit #
<br />I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county
<br />ordinances and state laws relating to well construction and or sewage system construction, and hereby authorize representatives of this
<br />county to enter upon the above-mentioned property for mspectlop purposes.
<br />Date Applicant
<br />EHD 43-02-007
<br />12/II/2002 i 1 { 'j.v'd,a .` ` pCENSEDCONT;tAGTORSDECLARATION.
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