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SR0069416
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4200/4300 - Liquid Waste/Water Well Permits
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SR0069416
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Last modified
9/9/2019 3:42:51 PM
Creation date
9/9/2019 3:37:29 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0069416
PE
2902
FACILITY_NAME
SHEA MOUNTAIN HOUSE PROPERTY
STREET_NUMBER
174
Direction
W
STREET_NAME
ALDRICH
STREET_TYPE
PL
City
MOUNTAIN HOUSE
Zip
95304
APN
26209013
ENTERED_DATE
4/11/2014 12:00:00 AM
SITE_LOCATION
174 W ALDRICH PL
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
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Tags
EHD - Public
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JOB ADDRESS: !!�� V v �'4 V I�,� PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Di ision 3/the Business and <br /> Professions Cod dj )yype,nso i in full force and effect <br /> License I l� iration Dat I <br /> Date O Contractor cp i <br /> OWNER-BUILDER DECLARATION <br /> I hereby affirm that I am exempt from the Contractors 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 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 /> 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 /> ❑(am exempt under Section , B&PC for this reason <br /> Date: Owner: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm that I have @ certificate of consent to se -insure ora f�cate of Wo <ers'Compensation Insurance,ora <br /> certified copy thereof Sec Ion 800,Labor Code). / <br /> Expiration Date 0 2 � Company �( <br /> ❑C rtified copy is h reby furnished <br /> Certified copy is filed with the Environmental Health Department <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> (This section need not be completed if the permit is for one hundred dollars($100)or less) <br /> 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 <br /> as to become subject to the Workers'Compensation Laws of California. <br /> Date: Applicant <br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation <br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. <br /> 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 <br /> (Section 3097,Civil Code). <br /> Lender's Name <br /> Lender'Address <br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <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 /> 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,Califomia Administrative <br /> Code). <br /> ❑As owner-builder,I will not employ anyone to do work which would require a pe ;1agre <br /> vision of Industrial Safety,as noted <br /> above,unless such person has a permit to do such work from the divis on. <br /> ❑Division of Industrial Safety Permit# <br /> I certify that I have read this application and state that the above information correct. comply with all city d county <br /> ordinances and state fab <br /> s relating to well construction and or sewage system y authorize repro tives of this <br /> county to me upon ve-mentioned property for inspection purposes. <br /> Date l� Applicant <br /> EHD 4307 LICENSED CONTRACTOR DECLARATION <br /> 1015/07 <br />
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