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WP0042782
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042782
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Entry Properties
Last modified
1/25/2022 4:54:14 PM
Creation date
1/25/2022 4:48:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042782
PE
4372
STREET_NUMBER
1781
Direction
E
STREET_NAME
GRANT LINE
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
21307039
ENTERED_DATE
12/2/2021 12:00:00 AM
SITE_LOCATION
1781 E GRANT LINE RD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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Tags
EHD - Public
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JOB ADDRESS: <br />PERMIT #: <br />LICENSED CONTRACTORS DECLARATION <br />1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 <br />Professions Code -and mutiownen in in full fn— ane nfr.H <br />License <br />Date I <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, after, 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 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 ($500)): <br />❑ 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 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 />O I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and <br />Professions Code (BBPC): 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 />17 I 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 self -insure or certificate of Workers' Compensation Insurance, or a certified copy <br />thereof (Section 3800, o Code). <br />Expiration Date � \ WA-Xt Company <br />O Certified copy is hereby furnished <br />Qftrtified copy is filed with the Environmental Health Department <br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br />(This section need not be completed if the oermit is for one hundred dollars ($1001 or less) <br />I certify that in the performance or 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 Calffomia. <br />Date: <br />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 (Section 3097, <br />Civil Code). <br />Lender's Name <br />Lender's Address <br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br />0,Mreby certify that no excavation rive (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 (38) feet high. (Chapter 3.2. Group 2, Article 2, Section 341, Title 8, California Administrative <br />Code). <br />❑ 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 />certify that I have read this application and slate that the above informaticn is I ag comply with all city and county <br />ordinances and state l s relati g to well censtruction and or sewage system ns and b authorize representatives of this <br />county to enter upon th apov mentioned property for inspection purposes. <br />Date \ L7' �fo�-i Applicant �U <br />EHD43-02-007 LICENSED CONTRACTORS DECLARATION <br />6.2609 <br />
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