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JOB ADORE33: 1280 Dove Drive,Tracy,CA 95376 PERIM 0: 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 LIcen"0 899451 Expiration Date 06/30/2021 Date 06/29/2007 Contractor Middle Earth Geo Testing.Inc. I OWNER-BUILDER DECLARATION I hereby affvm trial 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 structureprior 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 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 frre hundred dollars(S500)) 0 I, as owner of the property.or my employees with wages as their sole compensation w111 do the work. and the structure 15 not intended or offered for sale(Section 7044. Business and Professions Cade 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 his own employees,provided trial such improvements are not intended or offered for sale If however, the budding or improvement is said 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 sale i 0 I.as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7634 Business and Professions Code(B&PC) The Contractor's License Law does not apply to an owner of properly who builds a improves hereon and who constructs for such projects write a contractors)licensed pursuant to the Contractors License Law.i 0 1 am exempt under Section BBPC for this reason Date Owner WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a Certificate of consent to sea-insure or a certificate of Workers Compensation Insurance or a certified ropy thereof(Section 3800. Code) Expiration Date L Lia 1011 Company Middle Earth Geo Testing Inc. O Certified copy is hereby furnished (Example provided,we can obtain a certified copy if needed) 0 Certified copy 1s filea with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (ThisKttpn need not be Completed if the permit is for one hundred dollars(5160)or less/ I certify that 1n the performance of the work for which this permit is issued I shall not employ any person.n 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 perut shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm trial there is a construdion lending agency for the performance of the work for which this permit is iasuea(Section 3097 Civil Code) Lender's Name Lender's Address DWISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 0 1 hereby certify that no excavation five (5) or mere 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) 0 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 do such work from the division 0 Division of Industrial Safety Permit 0 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-mentioned property for inspecbon Purposes Date Applicant EHD 4}02-007 LICENSEC CONTRACTORS DECLARATION a2"