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r- Y - 4T 'EXPIRED________ JoeAR@ imit.may have expired without Pmmrr#: Y nVlt'q!�l31°r}''111 �!p��>~dyb�l croRsl7ECLARAriav I hereby affirm that I am licensed under the provisions of Chapter 9(eornmenang with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect, License# C i7#80M.76 Dir n�We 6-30-2015 Date 3-11-1v Contractor L V John le.Hillside Geotechnical Drilling OWNERA DER DECLARATiON I hereby affirm that i am exempt from the Contractor's License Law for the fokvong reason;Section 7031.5, Business and Professions j Code: Any city or county which requires a permit to construct atter, improve,demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencng with::lection 7QCCq of Division 3 of'he Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section'031.5 by any applicant for a permit subjects the applicant ; to a civil penalty of not more than fare hundred dollars(5500)): 0 1. as owner of the property, or my employees with wages as their sole compensation,will do the work, and the structure is not intended or offered for sale (Section 7044. Business and Professions Code:The contractor's License Law does not apply to an _rarer of property who builds or improves thereon.and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale. It however the building or improvement is sold within one year of ccm*tion.the owner-builder will have the burden of proving that he ill not build or improve for the purpose of sale.) D i,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044.Business and Professions Code(t3&PC): The Comractor's License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) 111 am exempt under Section ._ B&PC for this reason Date: Owner: WORKERS'COMPENSATION DECLARATION hereby affirm 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). Expiration Date % __ Company......_......_ O Certified copy is hereby furnished 0 Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS`COMPENSATION INSURANCE i dThissection need rot be completed if the permit is for one hundred dollars($100)or less) i 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. Date: Applicant NOTICE TO APPLICANT: if,after making this Certificate of Exemption, you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. CCNJSTRUCTiON LENDING AGENCY 1 hereby affirm that there is a construction iending agency for the performance of the work for which this permit is issued ,Section 3097,Civil Code). Lender's Name Lender'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 13 1 hereby certify that no excavation five(5) or more feet in depth into which a person is required to descend, will be made In ' Connection with work authorized by the permit, and that no building structure, scaffodddng,falseworlc or demolition or dismantling thereof, will be more than thirty-six{36)feet high. (Chapter 3.2,Croup 2. Article 2.Section 341.Title 9,California Administrative Code). 13 As owner-builder,I will not employ anyone in do work which would require a permit from the Division of Industrial Safety,as noted atnove,unless such person has a permit to do such work from the division. 13 Division of Industriai Safety Permit 4 i certify that I have read this application and state that the above information is correct I agree to comply with all city and courry ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Date Applicant i £ria 43-e7 11C£34S£n CC)W7ttAC7DR cEciaa;,now j , 106M7 j