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Home My WebLink About14-966JOB SITE ADDRESS�� APN LOT TRACT .OWNER 'ADDRESS CITY AmaV6 ZIP. 'q /'(Q 7 TEL:.'. APPLICANT CONTRACTOR�Y �W�1 A ADDRESS CITY•''.f1� ZIP�TEL z b ARCH/ENG/DESIGNER' .: ADDRESS CITY ZIP' TEL.. • .. OWNER -BUILDER DECLARATION'., . - I hereby afrrm under; penalty, of perpiry that I -am exempt fm m! the 'GArdractor's State License Laiv for the reaso(s) F indicated below by the checkmark(s), I have placed next to the applicable ilem(s) (section 7031.5; Business and . Professions Code::Any. city or county that requires a permit to eonstructj alte ; improve, demolish,'orrepair any.'; structure, prior to its issuance, also requires the applicantf it the permit to file's signed statement that he or she is.licensed pursuant to the provisions of the contractor's State L cense Law,(Chaptart Commerichig with Section 7000 of Division 3 of the; BuMness andl�rofesslorrs Codej or.Uiat he or she is exempt from Ilcensure and the. basis for the alleged exemption, Airy violafion of.Section �703t5 by any applicant fora DermD subjectsthe applicant to a civil penalty. of not more than five hundred dollars ,($500). `.,`' e. applicant as owner of the properly or my,employees with wages as theirsolecompensation, will do U all of or U pottlons. of the,work; and the stricture is not intended or offered for sale (Sectlon.7044, Business and Professlons Code: The Contractors' State License Law does nottapply loan owner of propertywhd,through employees':orpersooal effort, tiullds; or improves the property, provided that the Improvements are not Intended or offered for sale; If However, the building or: .improvement is sold within one year of complellon, the Owner -Builder vall have the burden of proving that it was notbuitt 'or improved for. the purpose of sale.).'. U 1. as owner of the property; am exclusively contracting with; licensed Contractors to construct the project (Section: 7044, Business and Professl)wCode: The Comractors' Stile License Law'does notappy to an, owner of property wllo.' boildsa lmpm_v, sthereon: and who contracts la the projects with a licensed Contractor pursbant to the Contractors' State , License Law.) U I am exempt from licensure onifer the Contractol's State 6ee6se'16W for the fopowing reason(s):. ` _ r By my signature below I acknowledge that, except for my personal residence In which I most have resided for at least one year prior to completion of the improvements covered by this permit,i cannot legally sell a sbuclure that Have bulttas an owner -builder if it has not been constructed In its erdfrety by Ilcensed contractors. I understand that a copy of the applicable `taw, Section 7044 of the, Business and Professions Code Is available uponrequest when this applicatlon is submitted a at the following Web site: httWwww.leginfo.ca:gov)ralaw.htrnl DATE: SIGN • .: ..; ..: LICENSED CONTRACTOR'S DECLARATION r' ... I hereby affirm under penalty of perjury that I am licensed undef provisions'of Chapter,9 (commencing with Section 7000)' of Division 3 of the Businee+ss and Professions'Code,,and'my license is in 6if force'anb effect: LICENSE CLASS: f� 7�� , LIC NO.. /zj, i) DATE:: 'J ` " 'r>Uy CONTRACTOR: WORKER'S COMPENSATION DECLARATION I HEREBY AF FIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING,DECLABATIONS Lh.avq and will maintain a Certifiate.of Consent to Seff Insute for,Worker's Compensation, as pro vided'hy. ` Section 3700 0l the; Labor Code for thd periornanca of the work for which thispermit is sued.' yF Ihaveand will maintain Workers Compensation insurance, as required by Section 3706 of the Labor Cade'for, the performance of the work foi which this permit is Issued. My Worker's Compensation Insurance Caider and Policy Number are: A fl .'CARRIER %NL1/�L;-►�FCI^ra�V ,. 06L6NUMBFA (THIS SECTION NEED NOT BE COMR.Er-ED IF THE PFRMR IS FOR ONE R1NDRED DOLLARS ($I* OR LEM. I certify that in the performarx:e of the wmk for which this permit is Issued I stall not emphry any person In airy manner so as to,: become subject to the WakWs Compensation laws of California. And agree.6at 41 should tieconte subject to the Worker's Compensation provisions of section 3700 of labor Code I shall forthwith cam' pty with thosepruvisiars DATE:�PPLICAHT: WARNING: Failure to'secure Worker's Comperi'safion coverage;ts unlawful, and shell subject an employer to criminal penalties. and civil fWws'up,hi orie hundred, thousand'dollars ($100,000), In addibonao the cost Of the compensation„ ': damages as provided for in section3706 ol,the latbr code, interest, and artpmey's fees CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction Lending'Agency for.the performance of the work for which this permit is issued (Sec; 3097, Civ. C.)..', LENDER'S NAME LENDERS ADDRESS I certify that I have read this application and wen state. that the above information IS correct (agree to comply with all city and, jcountyordinances and state laws relating to builing construchan; hereby authorize ie' t lives ai this county to. ::enter upon,the.above-mentioned property for inspection purposes:' rFt a� aid E PERMITTE RINn X MIT - SIGNATURE SIGNATURE OF PERIfTTEE DA COMMENTS: RECEIPT q PAID 6Y -.VALIDATION. WHITE•= Department, Copy YELLOW RnanceGopy, PINK Assessor Copy, GOLDENROD Fie Copy, GREEN Applicant's Copy: