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t <br /> Jos ADDRESS: 501 Mt. Oso Avenue, Tracy, CA 95376 PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Durston 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 06129/2007 Contractor Middle Earth Geo Testing. Inc. <br /> OWNER-BUILDER DECLARATION <br /> I hereby affirm that I am exempt from the Contractor's 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 he is licensed pursuant to the provisions of the Contractors <br /> License Law(Chapter 9(commenting 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 Arty 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 /> 0 I,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 contractor's 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 own employees provided that <br /> such improvements are not intended or offered for sale. if however, the budding or improvement is sold within one year of <br /> completion.the owner-budder v ill have the burden of proving that he did not build or Improve for the purpose of sale 1 <br /> ❑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 Contractors 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 Contractors License Law) <br /> O 1 am exempt under Section BBPC for this reason <br /> Date: Owner <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to sett-insure or a certificate of Workers Compensation Insurance,or a certified copy <br /> thereof(Section 3800,Labor Code) <br /> Expiration Date - <br /> �c 'ZI ZG21 Company Middle Earth Geo Testing Inc. <br /> m Certified copy is hereby lurmshed (Example provided,we can obtain a certified copy if needed) <br /> Certified copy is filed with the Environmental Health Department <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> (This Aecton need not be wmoleledif the permitis for one hundred W1 1 r less <br /> I certhy 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 <br /> become subject to the Workers Compensation Laws of CalUomia <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 permit 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(Sectior 3097 <br /> Civd Code) <br /> Lender's Name <br /> Lender's Address <br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br /> O 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.or demolition or dismantling <br /> thereof will be more than thirty-six(36)feet high (Chapter 3.2, Group 2 Arlde 2.Section 341,Title 8, California Administrative <br /> Code) <br /> O As owner-budder.I will not employ anyone to do work which would require a permit from the Division of Industrial Safetyas noted <br /> above,unless such person has a permit to do such work from the division <br /> O Division of Industrial Safety Permit# <br /> 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 <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 mspect:on purposes. <br /> Date Applicant <br /> EHD 43-02-007 LICENSED CONTRACTORS DECLARATION <br /> 6.26-09 <br />