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May,?5. 2015 1:40PM Stan County Env Resources No, 3028 P, 2
<br />JOR ADDRESS: 1600-MULLM ROAD, STOCKTON,-CA-95206 --- --_-- PERMIT It:
<br />LIC1?NGED CONTRACTORS DECLARATION
<br />I hereby offlrm them I am licensed under the provisions of Cnapter 9 (corrin"dnq with Saotion 7000) of Division 3 of the SuAlni ms and
<br />Professions Code And my license Is in full force and eff"A.
<br />312017
<br />License ff 1002572 Expiration D --------- _
<br />Date _,.a 1 1<r.� I 1---- Contractor----- --- - �_------_
<br />OWNER -BUILDER DECLARATION
<br />I hereby affirm that I am exempt fram the Contractor's License Law (or Iho following reason (Section 7031.5, Buslnesa and Profamlone
<br />Cod O: Any city or county whiah requires a pormd to torlsUuct, ale(. Improve, dernollEh, or repolr any elrudwo, prlex to U IesuanoP.
<br />Also requires the appliranl (Or such permit to file a slgned sialerrfent that he ie licensed Iwwionl Ib the p/Ovlsl0n9 of the Contractors
<br />Licsnso Lay/ (Chapter 9 (coinmenrJng with Se011on 7000) of DlVlaioo 3 of the SoslneSc and Professions Cod9) or that he Is exempt
<br />herefrom and the Oasts for the 01*j6d ottempOon. Any vlola(lon of Section 7031-5 by trny appllcsnl for a permit aubjaei5 the epplioant
<br />to a civil penalty of not mora than We hundred do)Iars ($500)):
<br />d I, as owner of the property, or my employees \Kith wages as their Rote compenaadon, will do the work. nna the structure ic, trot
<br />intended or offered for Sete (Seclion 7044, Business and Profebalons Code: The contracmr'e License Law does not apply to an
<br />ovmer of properly who builds of Irnprove* thtreon, and who does such work hfmseff or though hie own employees, provided that
<br />such improverrlenls are not Intorded W orrered nor sale, If, however. the bullding or Improvement is sold within one year of
<br />complotlon. the owner -builder will have the burden of Provir,� that he did not build of Improve for the purpose of Bala.)
<br />❑ 1, as owner of the WopelTy. am eXdLJ0\ 4Iy eonlrann8 with licensed contfac:orl 16 26n6Roci the pro(ert (S2cll^n 7034, Buainess and
<br />Professions Code (BUG). The ConpeolbeA l kenae Lew doeb hot apply to an ovmer of property who uupds or Improves hereon,
<br />and wno conalructs for euoh prolecte with a ronbactor(s) IicenSed pufcvgn1 to the Conlraelces License Law.)
<br />❑ 1 am exempt under Section . B&PC for this reason
<br />Doto' owner:
<br />WORKER& COMPENSA71ON DECLARATION
<br />I hamby affirm that 1 have a certificate of consent to self -insure or a cenlflcate of Wolkere' Cornpansatlon Insurance, or a
<br />eenlfred copy thereof (Section 3800, Labor Code),
<br />Nxplratlon Dato- I ' Company -
<br />0 Certified copy is hereby furnished
<br />❑ Certified copy is filed with the Envlronmentel Health Department
<br />CEPTIFICATE Or EXE(APTION FROM WORKERS' COMPENSATION INSURANCE
<br />Mils. section need not bo j2gmlokod If the permit Is for one hun4[�� dollars 1$100) or less
<br />I Cenlfy that In the performance of the work for tvtdch this permit is issued, I shall not employ any person In any manner co
<br />as to become uUbject to the Workers' Compensation Laws of Cahfornle,
<br />Dato: Ad'7 rr j �i j- AppllmW CM'SOUM-1 mill Q f
<br />NOTICE TO APPLICANT: If, after makfng this Cerbfrcale of Exemption, you should become 0ub)ect to the Workers Compent.adcn
<br />provistons of Lhe Labor Code, you must forthtrith comply mlh such praVf 6IM5 or thla permit -shall be desmud revoked.
<br />CONSTRUCTION LENDING AGENCY
<br />I hereby affirm that there Is a construction lending agency for the performance of Iho work forwhlch this permit is Issued
<br />(Section 3097, Civil Code),
<br />Lender's Nano _ --- --- --- ---- —� �� -- ------------------� . __,.;.._. �_ _ ------
<br />LenderAddress------ — -- ._, w _ __------..-.._--___ ".�----- ------ �.,
<br />DIVISION 01 INDUBTAIAL SAFETY PERMIT CERTIFICATION
<br />h I hereby certify that no excavation five (5) or roxe feet in doplh Into yrh(cfi a person le r"kilred to desrsnd, vAl be made in
<br />connection vnth wprk authorized by the permit, and that no bulloing structure, ac0oldin0, falsewcrk, or demolition or dismantliflg
<br />trlereof, will be more than thlrty,elk (38) foot high. (Chapter 5.2, Group 2, Article 2, Section 341, TiLle 6, Callfornis Administrative
<br />Code),
<br />❑ AS owner•bulWet, I %%ill not employ anyone to do work y hlch would roQUire a pormil from lrvm DNtslon of Indumrial Safety. as noted
<br />above, unieae such person has a permit To do euoh work from the diyl-W.
<br />❑ Divleion of IMU0141 8e(ely Permft 1
<br />I wKfy that I hove read li is sppiicalion and state that the above information to COTfBCL I agree ID Dm -ply \vith all city and county
<br />ordinances and state.t5vrs relating to well conslruCtion kind or lrawoje eyslam ci tn&truCUon, and hereby eulhodto represenleWes of this
<br />county to enter upon the above-mentioned property for (nspeellon purprAas,
<br />AppliranI ,_,-_ .. .----------
<br />ERD 4347 L1cEtt:E6 r-ONTPACTOP O"eCUIRA.TtM
<br />ID/JQi Jo3- rao. 2015-90 1-2
<br />Received Time May, 15. 2015 1:42PM No, 8134
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