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'I-101 BCH #12919 JOBADDRESS: 2440 DANIELS STREET MANTECA CA 95336 PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am It, under the provisions of Chapter a(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license Is In full force and effect License# 804431 Expiration Date 8/31/2013 Date 1/21/2013 Contractor JONES COVEY GROUP, INC. OWNER-BUILDER DECLARATION I here ffirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Code: Any a county which requires a permit to construct alter,improve,demolish,or repair any structure,prior to its Issuance, also requires the nt for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter mencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt hefefrom and the basis for the ed exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five red dollars($500)): 0 I, as owner of the property,a my employe th wages as their sole compensation,will do the work,and the structure Is not Intended or offered for sale(Section 7044, Busine d Professions Code:The contractor's License Law does not appy to an owner of property who builds of improves thereon,endoes such work himself or through his own employees,provided that such Improvements we not Intended or offered for sale. If, ver, the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that. di build or Improve for the purpose of sale.) O I,as owner of the property,am exclusively contracting with licensed contractors to truct the project(Section 7044,Business and Professions Code(BBPC): The Contrectofs License Law does not appy to an owner rly who builds or Improves hereon, and who constructs for such projects with a contractor(a)licensed pursuant to the Contractors se Law.) El I am exempt under Section , BBPC for this reason Date: Owner: WORKERS'COMPENSATION DECLARATION I herebyalfirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). E piratlon Date 2/1/2013 Company GRANITE STATE INC. CO. Certified copy is hereby furnished 0 Certified copy Is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (Thisne n leted If it Is for red dollar 00 or less I certify that in the performance of the fen this permit is Issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation alifomis. Date: Applicant NOTICE TO APPLICANT: If,after making this Certificate of Exemption.you should become subjec ars'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there s lending agency for the performance of the work for Which this permil is Issued (Section 3097,CMI Code). Lender's Name Lender"Address DIVISION OF INDUSTRIAL sAF,ETY PERMIT CERTIFICATION t3 I hereby certify that no excavation five(5)or more feet In depth Into which a person to required to descend, will be made In connection with work authorized by the permit,and that no building structure,scaffolding,faisework,or demolition of dismantling thereof,will be more than thirty-sfx(36)feet high. (Chapter 3.2,Group 2,ANde 2,Section 341,Tide 8,Calffomio Administrative Cade). 10 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, mit unless such person has a perto do such work from the division. Division of Industrial Safety Permit 2012-908414 1 certify that I have read this application and state that the above information is correct I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system cons Dion,and h reby authorize representatives of this county to enter upon the above-mentioned property for Inspection purposes. Date 1/21/2013 Applicant ERD43a7 IICENSEDCONTRACTOROECIARATKxn it007