|
JOB ADDRESS: 422 E.Mariposa Road,Stockton,CA PERMIT#:
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business a ,.
<br /> Professions Code and my license is in full force and effect.
<br /> License# 499908 Expiration Date 10/31/2016
<br /> Date 05/28/2015 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 provisions of the Contractor's
<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 five hundred dollars($500)):
<br /> ❑ 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 Cade: The confractor's Lica.-se Lar does,iot 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 /> ❑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 Contractor's License Law.)
<br /> ❑I am exempt under Section . B&PC for this reason
<br /> Date: Owner:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> I hereby affirm 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 Code).
<br /> Expiration Date 01/01/2016 Company Travelers Property Casualty Company of America
<br /> ❑Certified copy is hereby furnished
<br /> 8 Certified copy is filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION F w I N INSURANCE
<br /> This section need not be co I e o ne d a 1 �MeSj
<br /> I certify that in the performanc e r fd� t pe issued,I sha�I mploy any person in any manner so
<br /> as to become subject tc the rke mpensation Laws of Cal
<br /> Date: [!prrtli l la ' I"., ,
<br /> i t�r^ ^.
<br /> NOTICE TO APPLICANT: If, after mak �Fx�l>�ptrbct,^jotf hou gccyne subject to the Workers' Compensation
<br /> provisions of the Labor Code,you mil �wi h such provjsjpns.or'jpi ¢t,Mif�l[�i-e deemed revoked.
<br /> by ":. <. .
<br /> NSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agencv for the oerfornrance 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 /> ❑ 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
<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 thirty-six(36)feet high. (Chapter 3.2, Group 2, Article 2, Section 341, Title 8, California Administrative
<br /> Code).
<br /> ❑As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted
<br /> above,unless such person has a permit to do such work from the division.
<br /> ❑Division of Industrial Safety Permit*
<br /> I certify that I have read this application and state that the above information is correct I agree to comply with all city and county
<br /> ordinances and state laws relating to well 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 Applicant
<br /> EHD 43-07 LICENSED CONTRACTOR DECLARATION
<br /> 10/5/07
<br />
|