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JOB A06RESS: 2560 Stork Road,Port of Stockton,CA 95202. PERMIT III: LICENSED'-CONTRACTORS DECLARATION hereley,ef nn that I am licensed under(he provlslone sof Chapter 9(commending wth Section 7000)Or Division 3 of the Busli ess end Profeeabns Code and my ilcense is in full force.and affect License p 2933ze EXplretlon Date -6!30(12 . Data 5123112 Contractor WDC Expbratlon'and Webq " - OWNER-BUILDER DECLARATION I hereby tureen that I am exempt from the Contractors License Law for the'tollowin0 reason(Section 7091 5 Business and Professions Code: Any city or county which requires a permit to consWd eller,improve demolish,or repair any structure.Odor to its Issuance, also regyires the applicant for such permit to file a signed statement that he is licensed pursuant tc the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Buslness and poressionspC mit or that he subjects.the is exemppplit heraftom and the basis far the alleged exemption. Any violation of Section 7031.5 by any app licant for a to a Gvll penalty of not more their Ave hundred dollars(3500)): - ❑ ea ovmer of the property, or my employees with wages as their sole compensation,will do the work and the structure Is.not Intended or offered for sale (Section 7044, Business and Professions Coda: The contractors Licence Law does not apply to et owner of property who bullds or Improves thereon,and who does such work hlmself or through his own employees,provided net such.improvements ere not Intended or offered for sale. if,.however, Na building or improvement Is sold within one year of complella't the owner-builder will have the burden of proving that he did not bulid or Improve for the purpose of sale) ❑ as-owner of Ilia property,am exclusively conVacWg with licensed contractors to consuuct the project(Section 7044,Business and Professions Code(B&PC)' The Contractors License Law does not apply to an owner of property who builds or Improves hereon, and whoconstructs for such proiects with e contractors)Ilcensed pursuant to the Contractors License Law.) ❑I em exempt under Section S&PC for this reason Date: "Owner WORKERS!COMPENSATION DECLARATION thereby affirm that I have a certificate of consent to self-Insure_or a certificate of Workers'Compensation Insurance,ora cera fled.copy thereof-(S hon 800,Labor Code). ( / CorllPany Expiration Date -� - El Certified copy is hereby umished kf-Sedlfiecl copy is Ned with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE '(This section need not be Completed It the permitis for one hundred dollars(S100)orsea an ersofl(n any,manner so '�- I certify.that In the dformance of the work for which this permute Issues, sna vY-- Yp pe ion Laws of astobecome subject to the Workers'Compensat Date: Applicant NOTICE 70 APPLICANT If, after making NGDenlfcate of Exemption you shoultl become subject to the Workem'Compensation Provisions of the Lebon Code,you roust forthwith comply with such provisions or this pertnll%hall be doomed revoked. i•(l CONSTRUCTION LENDING AGENCY 'SS hereby affirm that there is a construoron lending agency for the performance of the work for which this permit Is isauetl • (Section 3097,Civil Code). y, - Lenders Name - "- - Lender'Address _. DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION v, a is required to descend, will be made In falsework,or demolition or dismantling bv" ❑ I.hereby certify that no ex4}Vatlon the (5) it more heat In depth id to which a Person True S.California Administrative` -.+ - contraction with work authorized'bY the permit,h.(that no 3.2,pullr structure, le 2-Sect thereof VflIIbe mare then Nsrty-six(36)feet'high.(Chapter 3.2,Group 2,Article 2,Section 341, ❑ , will not employ anyone to do work whichtwould As ovmer builder1 require a pemllt{mm the Division of Industrial Safety-ei noted above unless such person has a pennitio:do duck work fromlhe division ❑DM3ienoflndusldal Safety'Parmlt$,_� with all city and.county., 5h.'L erdlnancas end state laws his spP Io we cons aWto i and of sewage system DonaWcllon,and hereby.aulhorize represenlallves of this �x I tartly that have read this eppllcallon and state that Ne above in Id correct 1 agree to comply rel ting county to anter upon the are propertyforinspaction;purpoae%• Applicant .. Data LICENSED CDNTRACTCR,EDWNTION Ma107r o 1x3