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JOB ADDRESS: PERMIT#:
<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#, Expiration Date
<br /> Date Contractor
<br /> OWNER-BUILDER DECLARATION
<br /> ~ I hereby,affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professiotis Code: Any city or county which requires a'pernvt 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($500)):
<br /> ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not
<br /> intended or'offered for sale (Section 7044,4Business and Professions Code: The contractor's License Law does not apply to an
<br /> owner of property who builds or improves thereon, and who does such work himself or through his own employees,provided that
<br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of
<br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.)
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business
<br /> and Professions Code (B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> f hereon,and who constructs for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
<br /> ❑I am exempt under Section B&PC for this reason
<br /> Date: Owner
<br /> WORKERS' COMPENSATION DECLARATION
<br /> I heWkL=m ave a ificate co se -'nsure, r ificate of Worker ' ompensation Insurance,or a certified
<br /> OEereo (S ion 0, or C
<br /> x a omp y V r
<br /> ❑ o is her ni I RE LW)
<br /> ❑Certified copy is filed with the Envifoiimental'Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
<br /> (This section need not be completed if the permit is for one hundred dollars.($lb0)or lei
<br /> I certify that in 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 subject to the 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'
<br /> Compensation provisions of the 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 there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender' Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ Thereby certify that no.excavation five (5) .or more.feet_in..depth_into which-a.person-is..required to.-descend, will be made in
<br /> connection with work authorized by the permit, and that no building structure,scaffolding, falsework, or demolition Or dismantling
<br /> ` thereof, will be more than thirty-six(36) feet high.-(Chapter 3.2, Group 2,Article 2, Section 341,Title 8,California Administrative
<br /> x Code). A
<br /> ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as
<br /> noted above,unless such person has a permit to do such work from the division.
<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 inspection purposes.
<br /> Date Applicant 2
<br /> EHD 43-02-007 LICENSED CONTRACTORS DECLARATION
<br /> IV 11/2002
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