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doBADDRE&5:4223 Mcdougald Boulevard, Stockton. 95206 PERMIT#: LICENSED CONTRACTORS DECLARATION I hereby amml alai 1 am I:censeu under the provisions of Chapter 9(Commencing with Section 7000)of Division 3 of me Business and Prolesslons Code and my license is in fun force and effect. License# 804196 /V"M On Data 12131/13 Date - // - / -� Contractor OWNER-BUILDER DECLARATION I hereby affair mat 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,after,Improvedemolish,or repair any structure,prior to its Issuance, also requires the applicant for such penny to ale a signed statement mat he is ncensed pursuant to me provisions of the Contractor's tkense lav(Chapter 9(commencing with Section 7000)or Division 3 of me Business and Processions Code)or mal rhe Is exempt herefrom and me 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(4500)): 0 I,as owner of the property, or my employees wall wages as aMlr sole compensation,will do a4 work, and the SINCh1R 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 i mpraws thereon.and who does such woo(himself N mmngh his own employees, provided that such improvements are rot Intended or offered for sate_ If, however, the building or unproven ent 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.) 11 I.as owner of he property.am exclusively contracting with licensed contractors to construct the project(Section 7044.Business and Professions Code(B&PC): 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 contractors)licensed pursuant to the Contractor's License Law.) 0 1 am exempt under Section . B&PC(or this reason Date: Owner: WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure or a certificate of Wo kers'Compensation Insurance,or a certified copy thereof(Section 3800,Labor Code). Expiration Data 7/19113 Company Acord *Certified copy Is hereby furnished O Certified copy is filed with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE (This section need not be completed ifthe pennil is for one hundred dollars(S 100)or less) I certify that in the perfomnance 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: It. after making this Certificate of Exemption,you should become subject to me Yorkers•Compensation provisions of ate Labor Cue,you must renal comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affmf that there is a construction lending agency for the performance of the work for which this fil l is Issued (Section 3097.Civil Code). Lender's Name Lender Addreas DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION A I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend. will be made in cm,,cson whit work authonzed by the permit.and that no building structure,scaffadilg,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,Calaomla Administrative Code). O As owner-hullder.I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as rioted above,unless such person has a permit to do such work from the division. ❑on iswn of Industrial Safety Permit# I certify mal 1 have react this application and state that the above Information is Comecl. I agree to com Ith all aunty ordinances and stale laws relating to well construction and or sewage system construction hereby ar e rep IN of this county to enter upon me aIw_ ve-mentioned property for inspection purposes //// Date 2- I�- Z� Applicant END an.ai licensed CONTRACTdr aecl T1oN t9lLor