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Joe ADDRESS: 350 E Mt. Diablo Avenue. Tracy, CA 95376 PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby affirm tha: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# 899451 Expiration Date _ 613012021 Date_Q-6Z22aQQ7 Contractor Middle Earth Geo Testing, Inc. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors 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 for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors 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 violation 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)) ❑ 1 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 contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through hls 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-budder will have the burden of proving that he did not build or improve for the purpose of sale) ❑1 as owner of the property,am exclusively contracting with licensed contractors to construct the protect(Section 7044.Business and Professions Code(BBPC) The Contractor's License Law does not apply to an owner of property who builds or improves hereon and who constructs for such projects with a contractor(s)licensed pursuant to the Contractors License Law.) ❑1 am exempt under Section BBPC for this reason Date: Owner WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers Compensatior insurance.or a certified copy thereof(Section 3800 atwr oder Expiration Date 2 ZC Lt Company Middle Earth Geo Testing, Inc. ®Certified copy is hereby furnished (Example provided,we can obtain a certified copy if needed) ❑Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100)or less, I certify that in the performance of tt•e 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 It. 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 ❑ 1 hereby cenify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by the permit. and that no building structure.scaffolding,falsework,or demolition or dismantling thereof.will be more than thirty-six(36)feet high (Chapter 3 2, Group 2 Article 2, Section 341 Title 8, California Administrative Code) ❑ As owner-budder.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 permit to CIO such work from the dives+on ❑Division of Industrial Safety Permit# _ I certify that I have read this application and state that the above information is correct I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction.and hereby authorize representatives of this county to enter upon the above-menbonea property for inspection purposes Date Applicant EHD Q-Oc-0A7 LICENSED CONTRACTORS DECLARATION 626-Qo