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r r <br /> Jos ADDRESS: 751 W Lowell Avenue, Tracy, CA 95376 PERMIT#: <br /> it <br /> LICENSED CONTRACTORS DECLARATION <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and <br /> Professions Code and my license is in full force and effect <br /> License# 899451 Expiration Date 06/30/2021 <br /> Date 06/29/2007 Contractor Middle Earth Geo Testing, Inc. <br /> OWNER-BUILDER DECLARATION <br /> I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031.5.Business and Professions <br /> Code. Any city or county which requires a permit to construct,alter Improve,demolish,or repair any structure, prior to Its issuance. <br /> also requires the applicant for such permit to file a signed statement that hes licensed pursuant to the provisions of the Contractor's <br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt <br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant <br /> to a civil penalty of not more than five hundred dollars(S500))' <br /> O 1, as owner of the property, or my employees with wages as their sole compensation, will do the work. and the structure Is not <br /> Intended or offered for sale(Section 7044. Business and Professions Code. The contractors License Law does not apply to an <br /> owner of property who builds or improves thereon.and who does such work himself or through his oven employees provided that <br /> such improvements are not intended or offered for sale If. however, the building or improvement is sold within one year of <br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale) <br /> 0 I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044 Business and <br /> Professions Code(B&PC) The Contractor's License Law does not apply to an owner of property who builds or improves hereon, <br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) <br /> O 1 am exempt under Section B&PC for this reason <br /> Dab: Owner <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers Compensation Insurance,or a certified copy <br /> thereof(Section 3800.L bor de) <br /> Expiration Date 4.01A Company Middle Earth Geo Testing. Inc. <br /> ®Certified copy is hereby furnished (Example provided.we can obtain a certified copy if needed) <br /> O Certified copy is filed with the Environmental Health Department <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> (This section need not be comoleteC d the Dermt is for one nundred dollars(S10o)or less! <br /> I certify that in the performance of the work for•Much this permit is issued I shall not employ any person in any manner so as to <br /> become subject to the Workers Compensation Laws of California <br /> Date: Applicant <br /> NOTICE TO APPLICANT If after making this Certificate of Exemption, you should become subject to the Workers Compensation <br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permu shall be deemed revoked <br /> CONSTRUCTION LENDING AGENCY <br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Section 3097 <br /> Civil Code? <br /> Lender's Name <br /> I <br /> Lender's Address <br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br /> 0 1 hereby certify that no excavation five (5)or more feet in depth into which a person is required to descend, will be made in <br /> connection with work authorized by the permit,and that no building Structure,scaffolding,falsework.of demolition or dismantling <br /> thereof,will be more than thirty-six(36)feet high (Chapter 3.2 Group 2.Article 2.Section 341, Title 8.California Administrative <br /> Code) <br /> 0 As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted <br /> above,unless such person has a permit to do such work from the division <br /> 0 Division of Industrial Safety Permit# __ <br /> I certify that I have read this application and slate that the above information is correct I agree to comply with all city and county <br /> ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this <br /> county to enter upon the above-mentioned property for Inspection purposes <br /> Date Applicant <br /> EMD 43-02-007 LICENSED CONTRACTORS DECLARATION <br /> 6.24-09 <br />