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JoIaAlipttEss: 18775 Tl. .MAINE AVE. TRACY
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<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
<br /> and Professions Code and my license is in full force and effect.
<br /> License g .290813
<br /> Expiratton Date 5-3,1_0F3
<br /> �I Date 12-'27-07 Contractor HENNINGS EROS DRILLING CO.
<br /> INC-
<br /> ,i OWNER-BUILDER DECLARATION
<br /> 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and
<br /> Professions Code: Any city or county which requires a
<br /> r any structure,prior to
<br /> its issuance,also requires the applicant for such permit to Permit
<br /> asigned statement that he is construct,alter, improve,licensed pursuant emolish,or tto the Provisions of the
<br /> Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he
<br /> is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 b an a licant for a
<br /> the applicant to a civil penalty of not more than five hundred dollars(5500)): y y ppPermit subjects
<br /> ❑ 1,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 Code: The contractor's License Law does not 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 /> j 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 ofproving that Ire 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
<br /> and Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves
<br /> hereon,and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
<br /> r ❑1 am exempt under Section , $
<br /> &PC for this reason
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<br /> Date:
<br /> 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 certified
<br /> COPY thereof(Section 3900,Labor Code),
<br /> Expiration Date 1-1-08 Company STATE CGMPENSATION INS. FUND
<br /> ❑Certified copy is hereby famished ,
<br /> IN Certified copy is filed with the Environmental Health Department
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<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> This section need not be eom leted iftlic 13crmit is forne hund dA olio 100) 1 c ss
<br /> I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to
<br /> I become subject to the Workers'Compensation Laws of California.
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<br /> Date*
<br /> Applicant
<br /> NOTICE TO APPLICANT_ If, after making this Certificate of Exemption,p you should become subject to rho Workers'
<br /> ii Compcnsa6on provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> P CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section
<br /> 3097,Civil Code).
<br /> Lender's Name
<br /> Lender'Address
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> ❑ i 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 /> 1 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 /> Com).
<br /> ❑As owner-builder,1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety,
<br /> noted above,unless such person has a permit to do such work from the division. as
<br /> 17 Division.of Industrial Safety Permit B
<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
<br /> Applicant
<br /> EHD 43-02-007
<br /> 12/4112002 LICENSED CONTRACTORS DECLARATION
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