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JOB ADDRESS: PERMIT#: 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. License# 969927 Expiration Date 02/28!2022 Date 10/14/2020 Contractor Taber Drilling OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's 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,p-or 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 five hundred dollars($500)): ❑ I, 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 contractor's 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 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-builder will have the burden of proving that he did 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) ❑1 am exempt under Section BBPC for this reason --- --------- -- Date: �o ZA d Owner -- -- WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code) Expiration Date 08.15 2021 Company Slate Fund ❑Certified copy is hereby furnished ®Certified copy is filed with the Envirorimenta I 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 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 11 after making this Certificate of Exemption,you should become subject to the Workers' Compensation provisions of the Labor Coda,you must forthwit h comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction tending 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 certify that no excavation five (5) or more feet n 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-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above.union such person has a permit to do such watt from the division- El Division of Indu*W Safety Permit I codify that I have reed th a application and state that the above 711omtatian is corracL I agree to comply wth at city and county adkisini a and staft taws nNlnp to yeti conal uciot and or sewpe system eorratructim,and hereby auttortm reprssentoNves of this county b/nlsr upon this above4naniated property for Impaction papoaa. Date 10 15 2020 AWW..t BID 43402-on-/ LICENSED COWrnAcloms DECLARATM s2"