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DEPARTMENT OF ENVIRONMENTAL RESOURCES Hazardous Materials Division Business Name: ,,-bNE 9qRv1o_e Owner's Name ?Q&C-P___T 1QG�__ Busi.-nes�Locatjon:1i� l �(l�� ZipQ7�(�j G- X I_ os oS : C' Mailing Address (if different): F105cfi zip LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under 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 Class _ License No. /J �;-iZ' (� Date: - 010[0 Contractorb+5 +5 1, L1 ne- OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior 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 Law(Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom 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 notmore than five hundred ($500.00) dollars. ( ) 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 (Sec- 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 (Sec. 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 contracts for such projects with a contractor licensed pursuant to the Contractor's License Law- ) I am exempt under Sec. B & PC for this reason: Date: — Owner: WORKER'S COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof (Sec- 3800, Lab, C). ' Policy NO.oI K Rm�Company I L)D � r � n �- }� ( )Certified copy is hereby furnished. ( )Certified copy is filed with the county building inspection department of Stanislaus County - Date: _15�� 1 ounty_Date:! 1 3 I" l R CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if 11" permit is for one hundred ($100.00) dollars or less - 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 Worker's Compensation Laws of California. )ate: Applicant: 40TICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation rovisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. :ONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C) ender's Name ender's Address CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. f AGREE TO :OMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING T ING CON RUCTIONAND HEREBY UTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE WIT ME31D�PECTION URPOSES. ,ATE: iA I l � SIGNATURE OF APPLICANT OR AGENT 19--f0