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JogAotxtEss. 800 West Mos:s"c,Lathrop,CA 95330 PCRKfT LICENSED CONTRACTORS DECLARATION I hereby affirm that I are fcensod under the provisiomi of Chapter 8(commencing with Section 7000)of Division 3 of Che Business and Professions Code and my licerise is in full force and uffect. Ucenso g 71007/9 Expiration Date 7131115 Date -i ' t COrttrattork WN fk6 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Cortracmr's bronse Law fix the fallowlinr reason(Section 70315.Mmuness and Profession-, Code: Any city or catty which muires a permit to Construct after,trnprove,tdemoksh.or repair any saucrvre,prior to its Issuance. also repuires the appfcard for such palma to Be a signed tWom+nt trial he is frefrod pursuant to Cee proviseons of to Contractor's Llama Law(Chapter 9(commencrg with Secbw 7000)of Division 3 of the Business and Professions Code)or tint he is exempt herehont and the basis for the alleged exomptim. Any vi iiation of Suction 7031.5 by any 000,Cant for a Permit subjects the applicant to a chit penalty of not mora than Por!hundred dollars(5500)). O 1,as owner of the pfopony,Of my ompknyeas will wages as Iheu sole ccrmpensaton,wvl do the wink,and the stnrW re Is net intended or offered for sale(Section 7044.Business and Professions Coda:The contrac:ors Licanoe.Law does not apply to art owner of property who builds or Improves thereon,and who does such we*himself or through his own employees,provided that such Improvements are not intended or o%led for saki. If however.the buddm or improvement Is sok:wthn one year of Completion,the owrier-builder will haw the burden of proving that he did riot bu;1d Or improve for tits,purpose of sa!�) V h,as owner 0 the proprMy,am ezdustvoly conrracirg with licensed mntrtclors to cons"the protea(Section 71144.Business and Professtorts Code(BSPC): The Contractors License Law does not apply to an owner of property who bui:ds or improves hereon, mrd who constructs for such ptep4M wtth a ccrera=r(s)licensed pursuant to the Con7tctor•s Liren^sa Ww.) 13 1 am exempt under Sectiort �..__ BBPC`.or this reason Data: i WORKERS'COMPENSATION DECLARATION 1 hereby allium INA I have a certificate of consent to self4nsure or a certificate of Workers'Cornpertsation insurance,or a Certified Copy thereof(Serbon _ 3800Labor Code). Expiration Date Comp)1, ry ---- ❑Corthed copy is ""rhdrebyfurnished ❑Certified Copy is filed with the Environmental Neafih Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This rection ri d not bis cerebri died hf the tlertmtt is W one hundred dollars(51001 air tusul I certify that in the performance of the work for vAllch this Permit is issued.i sided not rdtThpjoy any person in any n1,ar*.ner so i or,to become subject to the Workers'Compensation Laws of California. f Date _ Appficarlt NOTICE TO APPLICANT:ft,after making Cas CortMcaw of Exemption,you should bow sut>pra to tie Vyorkers'Con>fxra`'>fbn I provisions of the labor Cddo,you must forttwhith comply w!th such provisions or this permit snag be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constniction$ending agency for the performance of the work for which this pert-nit is issued (Section 3097,Civil Code) Lender's Name "'- i Lander Address i DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 13 1 hereby certify that no excavation five (5)ar more feel in depth'rite which a person is req uired to descend,n o di mads N 1 comedian with work �d by the permit and Cant ria beading strucerru,scaffolding,ta��k.or demoffwnt air dismantling , thereof,ell be mora mien tairtY-six(36)feet high.(Ctmptru 32,Grnep 2.Article 2.Section 341,Title 8,Catfarnia Admin;straSive i Code). 13 As owrei-widef,I will not employ anyone to do work whin would require o Permit from btu C!ri,iGn of IrxlusL4el S:dcy.as noted above,unless,.,:h fz•rvsara Kis a pormx to do Ar-b work from the dansion 13 Division of irduutrtai Safety Perini!# I certify#tat i hifw n:ad itti5 appsratkxh and state Ctfi t share informoWn is Correct-I cu3rae n ctxnCly mttn as city and county ordinaroes and state lairs rniatng to well construction and or sewage system cxrtstnhdiart,and hereby atRhorize representatives at this county to enter upon ate ahovo tror+t'cr>r-}d rxr peM for Inspection rwrP :s. Data _-- Applicant L:CENS[.D Cil TrACTOR tXC"AMT1004 F+m astir f O'Sla7