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1 JOB ADDRESS: PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm thal I um licensed under the provisions of Chapter 9(commencing with Section 70M)of Division 3 of the Businus and Prolessinns Code, and my license is in full force and effect. License N Exp.:Dalc Date Contractor OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Sec.7031.5.Business and Professions Code;Any city or county which requires a Permit:o construct,alter,improve,demolish,or rapairany structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuaru to the provisions of the Contractor's 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 basis for the alleged exemption. Any violmtion of Scctinn 70j l.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(E5rx1)): ❑1,as owner of the Pmpery,or my employers with wages as their sole compensation,will do the work,and the strhhctntre is not intended or offered for sale le Business and Professions Code:The Contractor's 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 arc not'leltMed or offeed for sale. If,however,the building m improvement is sold within one year of compiction,the owner-bui Idcr will have the burden of proving that he did not build or improve for the putprur;of sale_) ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profession Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a corwraclot(s) licensed pursuant to the Contractor's Geense Law.) ❑1 am exempt under Sec. .13 A P.C.for this reason Dale Owner - WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of WO1kerb'Compensation Insurance,or a ecrtified copy thereof(Sit.3g00, Lab.Q. Exp.Date Compatry 13 Certifcd copy a hereby furnished ❑Certified copy is filed with the County Building Inspection Divisioa CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed,if the Permit is foronc hundred dollars(SI00)or less) I certify that in the performance of the work for which this perntit is issued.I shall not employ any person in any manner so as to become suhjeci to the Workers'Compensation Laws of California. Date _Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. I-cndcr's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑1 hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be make in connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be rmTc than thirty-six(36)feet high. (Chap.3.2,Grp 2,A.n 2,Sec 341,Title a.C.A.C.). O As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as no!ed above,unless such Person has a permit w do such work from the division. ❑Division of Industrial Permit No. 011 application and state that the above information is correct. I agree to comply with all city and county ordinansces and stale laws relating to well construction and or sewage system constmction,and hereby authoriu represenutivu of this county to enter upon the abovc-nientioned sl scs. v Dalc_ Applicant ' JAM@1 ,rj0