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Joe ADDRESS: 2550 Stork Road,Port of Stockton,CA 95202 PERMIT R: LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license Is In full force and affect License it 293328 Expiration Date W30112 Date 5/23112 Contractor WDC Exploration and Wells v' OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Code: Any city or county which requires a permit to construct, alter,improve,demolish,or repair any structure,prior to Its Issuance, also requires the applicant fpr won permit to file a signed statement that he Is licensed pursuant to the provisions of the Convectors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violetion of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)): ❑I, as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not Intended or offered for sale(Section 7044, Business and Professlons Code: The contractors License Law does not apply to an owner of property who build$or improves thereon,and who does such work himself or through his own employees,provided that such Improvements are not Intended or offered for sale. If,however, the building or improvement is sold within one year of completion,me owner-builder Wit have the burden of proving mal he did not build or Improve for the purpose of sale) ❑I,as owner of the property,am exclusively convecting with licensed contractors to construct me project(Section 7044,Business and Professions.Code(B&PC): The Contractor`3 Ucense Law does not apply to an owner M property who bads or Improves hereon, and who concocts for such projects with a contractor(s)licensed pursuant to the Contractors Llceilse Law.) ❑f am exempt under Section , B&PC for this reason Date: Owner. WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-Insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(S tion 80abor Code). Expiration Date / 0,LCompany ❑Certified copy Is hereby nished 40*6ertlfied copy is filed with the Environmental Health Department CERTIFICATE of EXEMPTION FROM WORKERS'COMPENSATION INSURANCE '.abl$sedlon need not be oomDleta If the permit is for one hundred dollars(5io0 orr lei I certify that In the performance of the Work for which this permit is issued,I shall not employ any person In any manner so ae to become subject to the Workers'Compensation LaWS of California. Date: Applicant NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become subject to the Workers'Compensason provisions of the Labor Code,you must forthwith comply with such provisions or this permit shalt be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there IS a construction lending agency for the performance of the Work for which this permit Is issued (Section 3097,Civil Code). Lender's Nanta Londer'Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ecaHmding,falsework,or demolition or dismantling ❑ I hereby ceruN foal no excavation flue i5) or more feet In depth into which a person Is required to descend,will be made n connection with work authorized by Ne Ps"It; and mat no building structure,2,Art, .thereof,will be more than thirty-six(38)feet high.(Chapter 32.Group 2,Article 2.Section 341,TIUe e,Cellfomle Admimsireuva Code). ed E3 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as not above,unless such person has a permit to do such work from the divl$IOM ❑Division of Industrial Safety Permit A,___---- with all city and county 1 certify that I have read this application and state that the above information Is correct I agree to comply countyitoenterGrand upon state to a sharing to wall propenbey for Insor pection Purposesstm consiruc9on,and hereby authorize representatives of This Applicant Data UCENSED coirr P TOR DEOVAATiON EHO 0107 10$'07