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I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicableitem(s)
ction.7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure,. prior to its issuance, also requires the applicant for
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter.9 (commencing with Section 7000)of Division 3 of the Business and
fessionsCode) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
more than five hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sole compensation, will do 0 all of or C.) portions of the work, and the structure is not intended or offered for sale (Section 7044,
;iness and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the
rovements are not: intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner -Builder Will have the burden of proving that it was not built or
roved for the.pufpose of sale).
I, as ownetof;(he property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Cade: The Contractors' State License Law does not
ty tcan owner of'property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuantto the Contractors' State License Law).
I ane exempt,f qB,m, licensure under the Contractors' State License Law for the following reason:
myusignature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legall
'a, FOucture that I ham built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and
fessions CoAe, ie'a0ailable upon request whaiLyis appifc ' n is suhyitte _oft the following Web site:http://www.leginfo.ca.gov/calaw.html,
Tafum of Property Gwner or Authorized Agent LlNif�.�^ Date 1/28/21
TENSED =4TFA:CTOR'S DECLARATION- V
mby:,affirm urdar penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
_ License
COMPENSATION DECLARATION
L'AAiJ1aGiFA1LUR@?Q SECURE WORKERS' COMPENSATION COVERAGE I3 UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE
^F e4T
COMPENION, DAMAGES AS PROVIDED FOR IN SECTION 37DS OF THE LABOR CODE, INTEREST, ANDA TTORNEY'S FEES.
hereby affirm under"penalty, of perjury one of the following declarations:
I have and will maintain a. certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for
`ormance of the work for which this permit is issued. Policy No.
have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' companies'
Trance carrier and policy number are:
of Agent
Policy Number Expiration Date
Phone #
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 become subject to the workers' compensation laws of California, and-agre
if Ishould become ubjeot to theyw�o/lkers' com/pens tionprovisions of Section 3700 of the Labor Code, I shall forthwith comply with those provi Ions.
lature of Applicant _ �i !J ( .(' .QL Date V28/21
:1 ARATION RFr:A A f -Td -1 111NRTR11 . InN 1 FNiVNO ArPMrV
I hereby affirm under penalty of perjury thatIthere is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code).
Lender's Name Lender's Address
By my signature below,.) certify to each of the following:
I am the property owner or authorized to act on the property owner's behalf.
I have read this application and the information I have provided is correct.
1 agree to comply With all applicable city and county ordinances and state laws relating to building construction.
I.authorize representatives of this city or countyo e the abov 'd )fie .property for inspection purposes.
Signature of Property Owner or Authorized Age PrintPrope Owner's or Authorized Agent's Name Greg Chita Date 1/28/21
AC77ON DATE BY DECLARATION OF COMPLIANCE lM7NCODEOF FOR OFFICE USE ONLY
FEDERAL REGULATIONS PART 61 OF777LE40AND
PERMITEXPIREO OMDRULE1401
I SUBMITTED ASBESTOS N077FICA77ON TO.,
PERMITCANCELLED I ❑ EPA
PERMIT D(TENDED OTA I
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