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Jos ADDRESS: 500 East Louis Avenue,Lathrop,CA 95330 PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divi 'on 3 the Business and Professions Code a li ns�o I in full force and effect License# 4!Wel Exp(ratt Date t Date 11- -SIVO A Contractor_ OWNER43UILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following son(Section 7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter,improve, olish,or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signed statement that h licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 the Business and Professions Code)or that he is exempt herefrcm and the basis for the alleged exemption. Any violation of S on 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500)): ❑1, as owner of the properly, or my employees with wage as their sole compensation,will do the work, and the structure is not mended or offered for sale (Section 7044, Business d Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, d who does such work himself or through his own employees,provided that such improvements are not intended or offered r sale. If, however, the b ug&ng or improvement is sold within one year of completion,the owner-builder will have the burd of proving that he did not build or improve for the purpose of sale.) ❑I,as owner of the property,am exclusively cling with licensed contractors to construct tho project(Section 7044,Business and Professions Code(BBPC): The Contra a License Law does not apply to an owner of property who builds or improves hereon, and who constructs for such projects contraator(s)licensed pursuant to the Contractors License Law.) ❑1 am exempt under Section BBPC for this reason Date: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a cortificate of consent to self-insure or a certificate of Workers Compensation Insurance,or a certified copy thereof(Section 3600,Ltd orode). ^ Expiration Date I'Mk �-�'1 Company `J Wr-,,ertrfed copy is hereby furnished ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the ponnit is for one hundred dollars l$1(M)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 Card to of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code,you must forthwith ply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY hereby affirm that there is a constru n lending agency for the performance of the work for which this permit is issued(Section 3097, Civil Code). Lender's Name None Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five (5) or more fact in depth into which a person is required to descend, will be made in connection with work authorized by the parmit, and that no bulding structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty.-six(36)feat high.(Chapter 3.2, Group 2,Article 2,Section 341,Title 8, California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Di ' 'on of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. ❑Division of Industrial Safety Permit 4 I certify that I lav rea this application and state that the above information r cL I gree to y with all city and county ordinances and to relating to well construction and or sewage system conslru an here a orize representatives of this county to ante p n the bove-riawtioned property for inspection purposes. Date ` Applicant EHD 43-02-007 LICENSED CONTRACTORS DECLARATION 62&09