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<br /> JOBADDREEs: 2480 Toste Road,Tracy,CA 95377 PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> 1 hereby affirm that I am licensed under the previsions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code and my license is In full fame and effect.
<br /> License# C57-#499908 Expiration Date 10/31/2018
<br /> Date 2/15/17 Contractor Krazan&Associates,Inc.
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions
<br /> Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,
<br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the previsions of the Contractors
<br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt
<br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
<br /> to a civil penalty of not more than flue hundred dollars($500)):
<br /> 0 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,Business 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 /> 0 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and
<br /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or Improves hereon,
<br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractors License Law.)
<br /> 0 lam exempt under Section , B&PC for this reason
<br /> Date: Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affir l that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a
<br /> certified copy thereof(Section 3800,Labor Cafe).
<br /> Expiration Date 1/1/2018 Company Travelers Property Casualty Company
<br /> 0 Certified copy is hereby furnished
<br /> 10 Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> (This section need not be completed ifthe permit is for one hundred dollars($100)or less)
<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 sD
<br /> as to become subject to the Workers'Compensation taws of Calitomia.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation
<br /> provisions of the Labor Code,you must forthwith comply with such previsions 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
<br /> (Section 3097,Civil Code),
<br /> Lender's Name _
<br /> Lender Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> M I hereby cera(y 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 thirtysix(38)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title B,California Administrative
<br /> Code).
<br /> 0 As owner-builder,I will not employ anyone to do work which would require a pernit from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> 0 Division of Indushial Safely Permit#
<br /> I certify that I have read this application and state that the above information is cored I agree to comply with all city and county
<br /> ordinances and state laws relating to wall 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 2/15/2017 Applicant Krnzan &Associates.Inc.
<br /> EHO 43 17 LICA SED CONT CTCR DECIARATION
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