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JOB ADDRESS: 315 E 11 th Street, Tracy,CA 95376 PERMIT#: LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under the prornsions 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 06/30/2021 Date 06/29/2007 Contractor Middle Earth Geo Testing,Inc. OWNER-BUILDER DECLARATION hereby affirm that 1 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 Vie appllcanl 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 Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption. Any%notation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500)) ❑1,as owner of the property. or my urnployees with wages as their sola cornpensalion,will do the work. and the structure Is riot intended or offered for sale(Section 7044,Business and Professions Code.The contractor's License Law does not apply to an owner of property wtio 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 sola within one year of completion,the owner-builder will have the burden of proving that he d•d not build or improve for the purpose of sale.) ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(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 Contractor's License Law.) ❑I am exempt under Section _ BSPC for this reason Date: Owner WORKERS'COMPENSATION DECLARATION hereby affiml that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3E00.Labor C de) Expiration Date 2A 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 Heallh Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need riot be completed if the permit Is for one hundred dollars(51001 or less) 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[tie Workers Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be doomed 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 Nama Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five (5)or more feet in depth into which a person is required to descend, wil be made in connection with work authorized by the permit.and that no building structure,scaffolding,falsework,or demolition or dismanding thereof,will be more than thirty-six(36)feet high (Chapter 3 2,Group 2,Article 2,Section 341, Title B,California Administrative Code). ❑ As ownor-buildor,I will riot 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 do such work from the division ❑Division of Industrial Safely Permit# --- I certify that 1 have read this application and state that the above information is cored. I agree to comply with all city and county ordinances and state lam relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Date Applicant EHD 43 02001 LICENSED CONTRACTORS DECLARATION 6-26M