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800 West Nfoss"e,Lathrop.CA 95330 JOB ADDRFS5:—_ PrAMR 9: — LICENSED CONTRACTORS DECLARATION I hereoy afnrn rRn I am hcxxe eu j ander the provisions of Crupter 9(comm., cinq,lith a.rt)on 7000)of Division 3 of the Busmoss and Professions Code and my license is in hill forty and uff oo-. Uc,anso s 710079 Expiration Dab 7/31115 Date ��,}-1 11`- Contractor ( 't , 1 t' I h r 1 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from tlxr Cactraclora!-seen."Law for tie foliovirro reason(Section 7031 5,Business and Profess-ons Code: Any city or county which racuies a permit to ConStUCL after,improve,demclish,or repa.r any SITU are,prkhr to its Issuance. ai ro reouires the appkcant for such permit to file a signed statement chat no Is l censod pursuant to The provisions of thn Contractors License Law(Chapter 9(comrtlancrhg with Semon 7000)of Division 3 of the Bufwiass and Professions Codn)or that he is exempt herefrurn and the hvcr for the aliegod exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a r3vil penalty of not morn thvn fire hundred dollars($500)): O I,as owner of the properly.or my emdnyn.s with wages as their sale Compensaton.will do the wok,and the strtxArre Is not udended or offered for sale(Section 7044,P.usincss and Professions Coda The contractors Licerm Law does not apply to an owner of proporty who buJds or imprm-es thereon,and who does such work hmhself of through his own rmpioyr•eS.provided that such Improvements are not intended Or o'tlred for sale. If however,the budding or improvement Is sold wth n cine year of completion,the owner-buildor will havo the burd.xh of proving that he did not build or improve for the purpose of sale 1 or,,as owner of the wupedy,am exclusively contiacing with licensed contractors to construct the project(Section 7DU,Business and Professions Code(BBPC): The CDntia=0 License Law does not apply to an owner of property who bui'ds or improves hereon, nn-1 who cOrnhucs for such prD&.is w th a ccn ra=ga)licensed pursuant to the Conrntors License Law.) Q I am exempt under Section —_ BSPC for this reason Data: f1-�� /$� Owner. --- Li y ------—-- -- -- -- -- - .i WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insuro or a cortiffcalo of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Later Code). 11, c� I Expiration Date Com ny ------- O Cefthod copy is hereby fumished 1 O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE chis section decd not he cbrrlaleted if the Demut is for one hundred dollars($100)or less) I certify that in the perfornunce of the work for which this permit's issued.1 shill not employ any person in any manner so as to become wbfoct to the Workers'Compensation Laos of California. Date: Applicantt _—---- — —- — — h NOTICE TO APPLICANT:tf.after making this CedMcAa of Exemption.you should become x. bf."to me vL'crkers'Compertcatlon provirions;of the Labor Code,you must forthwith comply vrth such prcnshons or this permit shall be deemed reeked I CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constniction{endmq agency for the performance of fie work for which Mis permit is issued (Sed)on 309? C1,AJ Code) — Lender's Name Londcr Addross_ — - -- ----"— DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION D I hereby certify flat no oxcavanon five (5)a more feet in depth into wNc h a person s required to descend,will be made in connection with work authoeaod by tho pormat and uxd no building strtxturo,scaffolding.falscwork,or dertnolRion or dismantling thereof,will W mute than thirty-six(36)feat high.(Chaplet 32,r, up 2_Arbde 2.Seebcn 331,Title 8,California Admin'Stfabve Code). 13 A,ownerbu ldar.I will not employ anyoIt ne work from Ute dtviyonru ih rA,1 nR from the Dlvisron of tett^,rfuy.as noted nbov.,unless surth pa1n do strii parson has a pOr 0 Divlson of Industrial Safety Pemvt ay _-_. - 1 certify,the:I S=road tris apPgolf hoc twn dnd stale Ura the above informobon is correct 1 arynxn la mmply with all city find county em ccnstnxtkxl,oral hereto auNlerize��o[firs n.6nanrtns and statin tins rtnL-rtinq to well construction and w sewage cyst county to enter upon rho ahov rmerritonrd lxthpery for inspection purpose'. Data —.— Applicant _ Fern tW - -- �'CEtft.:A GOn IYl.CT03t UCCW var�pf.