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---1��'---- DEPARTMENT OF COIvIIvIUNITY&'DEVELOPMENT SERVICES - "' " "-
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p 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM 7HE CANTRACTORS LI� GdfBQB/CBfpOR
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w TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT fOR SUCH PERMIT TO FILE A SIGNED w P8110/DBCk
STATEMENT THA7 HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE UW(CHAPTER B(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AN�PRO- � POOVSP2
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V TION.ANVVIOLATIONOFSECTION7031.5BVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roaf
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Z WILL DO THE WORK,AND THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7a4I,BUSI� J
N NESS AND PROFESSIONS fADE:THE CONTRACTORS LICENSE LAW DOES NO7 APPLV TO AN OWNER OF =
PROPERTV WHO BUILDS OR IMPROVES 7HEREON,AND NT10 DOES SUCH WORN HIMSEIF OR HERSELF OR
� THROUGH HIS OR HER OWN EMPLOVEES,PpOVIDED THAT SUCH IMPROVEMEN75 ARE NO71N7ENDED OR m
w OFFEREDFORSALE.IF,HOWEVER,hiEBUILDINGORIMPFOVEMEN71SSOlDWI7HINONEVEAROFCOMPLE�
0 TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OH SHE DID NOT BUILD OR
Z IMPqOVE FOR THE PURPOSE OF SALE).
Q_ ❑I,ASOWNEROFTHEPROPER7V,AME%CLUSIVELYCONTRACTINGWI7HLICENSEDCANTRACTORS
70 CANSTHUC7 TNE PRQIECT(SEC.70�4,BUSINESS AND PROFESSIONS CODE:THE CONTRAC70R5 LI- V81U81i0f1 ADJ.AREA
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� ❑I AM E%EMP7 UNDER SEC. B.8 P.C.FOR THIS REASON Q
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DATE OWNER �
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFINM UNDER PENALTY OF PEHJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F 7HE BUSINESS AND PROFESSIONS CODE,AND Z
X MY UCENSE IS IN FULL FORCE AND EFFECT. — l
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� WORKERS'COMPENSATION DECLAFATION Q
� I HEHEBY AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECLARATIONS: Z
� _IHAVEANDWILLMAIN7AINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' 2
CAMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. w
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W I HAVE AND WILL MAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 770o Of THE LABOR CADE,FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS ��
ISSUED.MV WORKERS;COMPENSAypt�INS�1RAt�E CARHIER AND POLICY NUMBER AFE: CONSTRUCTION I��.
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� CARRIER v I 1 I � 1 ���Q PLAN REVIEW
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Z 1 CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T RMIT IS ISSUED,I MECHANICAL
(.'} SHALL NOT EMPLOY ANY PEFi50N IN ANV MANNER SO AS TO CA SU ECT TO THE I .�• A ,
(/� WORKERS'COMPENSATION LAWS ORNIA, D A E H IF I S OULD BECAME INSPECTION FEE /
= SUBJECTTOTHEWORKERS'CA ENSATI PRO 510 OF TION3000FT BOR I
CODE.%HA F�THWITH COMPL ITH T�I `�/'
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p DATE: b J APPLICAN: I R V IONS. SM PAN I�.._____._' /.
J WARNING FAILURE TO SECURE WORKERS'CAMPENSA710N COVERAGE IS UNLA L,AND SHALL BE ENERGY P/C +
� SU&IECTANEMPLOVEHTOCRIMINALPENALTIESANDCIVILFINESUPTOONEH DREDTHOUSAND ENERGYPERMIT
DOLURS(i100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CADE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: ~
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d CONSTRUCTION LENDING AGENCY pRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOFTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.�.
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� LENDER'S NAME
� LENDEP'SADDFESS �
� ICERTIFVTIIATIHAVEREADTHISAPPLICATIONANDSTATETFiATTHEABOVEINFOHMATIONISCARRECT. TOTAL FEES / /.
w I AGREE 70 COMPLV WI7H ALL CI7Y ANO CAUNTY ORDINANCES AND S7A7E LAWS RELATING TO BUILDING L
� CONSTRUCTION,AND HEREBV AUTHORIZE FiEPRESENTATNES OF THIS COUNTY TO ENTER UPON THE
� ABOVE-MENTIONED FROPERTY FOR INSPECTION PURPOSES.
Z � COMMENTS
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= RECPT.N0. PAID BY DJr� 7 VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanYs Copy
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