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JOB ADDRESS: 4343 N WilsonWay,Stockton,CA 95205 PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm that I 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 effect. License# 970772 Expiration Date 03/31/2020 Date 7/24/2019 Contractor Saletn Enginering(;rotip DBA Salem Well Drilling OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the follow ng reason(Section 7031.5,Business and Professions Code: Any cily or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance, also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvislon 3 o1 the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant(of a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)) E3 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 Professions Code The contractor's License Law does nol apply to an owner of property who builds 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,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sal:) Q I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code(BdPC): The Contractor's License Law does not apply to an owner of property who builds of improves hereon, and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) D I am exempt under Section , BBPC for this reason Date: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell-Insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Date 12/1/2019 ___ Company_Valley Forge Insurance Co pExCertified copy is hereby furnished E3 Certified copy is filed with the Environmental Healfh Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100)or loss) 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 as 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'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall 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 Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 411 hereby certify that no excavation five (5) or more feel In depth into which a person is required to descend, will be made in connection with work authorized by the permit,and that no budding structure,scaffolding,falsework,or demolition or dismantling thereof,wit be nave than thirty-six (36)feet high.(Chapter 3.2,Group 2,Article 2,Section 341,Title 8,California Admrnislfallve Code). 13 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permil to do such work from the division. 0 Division of Industrial Safety Permit 0 certify that I have read this application and slate that the above information is confect. I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system const tenon,and hereby authorize representatives of this county to enter upon the above-mentioned property for inw--ion purposes }i Date 7/24/19 _ Applicant _ / EHD 43-02-007 LICENSED CONTRACTORS DECLARATION 62609