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SPECT - DECLARATIONS EXPIRATION LICENSED CRACTORSDECLARATION INFORMATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectiot0)of Division 3 of the Business and Professions Code,and my license is in full force and effect Every permit issued by the Building License# Expiration Date Official under the provisions of this Date Contractor Code shall expire by limitation and become null and void if the building or OWNER-BUILDER DECLARATION work authorized by such permit is not I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.7031.6, commenced within 180 days from the Business and Professions Code:Any city or county which requires a permit to construct,alter,improve, date of such permit,or if the building demolish,or repair any structure,prior to its issuance,also requires the applicantfor such permit to file a or work authorized by such permit is signed statementthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 suspended or abandoned at any time (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt after the work is commenced for a therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a period of 180 days. Work shall be permit subjects the applicantto a civil penalty of not more than five hundred dollars($500.00).): considered abandoned if an ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work, inspection has not been approved and recorded within 180 days. 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.) , as owner of the property,am exclusively contracting with licensed contractors to construct the INSPECTION project. (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to INFORMATION an owner of property who builds or improves thereon,and who contracts for such projects with a contractor/contractor(s)license pursuantto the Contractor's License Law.) I am exemp under ec. of t Business and Pr f� sions de for the The San Joaquin County Building F1i� Inspection Division has installed an foI owl automatic recording device to receive Date Owner All inspection requests. This service will •be available 24 hours a day, seven WORKERS'C MPENSATIONDE LA RATION days a week. Calls will be taken off I hereby affirm under penalty of perjury one of the following declarations: the recorder at 3:00 p.m. every ❑ I have and will maintain a certificate of consent to self-insurefor workers'compensation,as provided workday and distributed for for by Section 3700 of the Labor Code,for the performanceof the work for which this permit is inspection the following workday. issuedl have wmaintain workers'compensation insurance,as re (2 compensaon nsurac , required by Section 3700 of the Labor request an inspection,please call F1I hadill itik � (209)468-3165. You will be requested Code,for the performance of the work for which this permit is issued. My workers'compensation to providethe following information: insurance carrier and policy number are: Carrier Policy Number 1. Permit Number(Mandatory) (This section need not be completed if the permit is for one hundred dollars($100)or less). 2. Your Name certify that in the performance of the work for which this permit is issued, I shall not employ any 3. Job Site Address and Nearest person in any manner so as to become subject to the workers'compensatio of California,and Cross Street agree that if I should become subject to the worke co nsation provisi ns of Section 3700 of the 4. Telephone Number Labor Co b I sh I forthwith comply with those pr C7 /� 5. Day Inspection Preferred � / 6. Type of Irupection Date Applicant i (i L WARNI U E TO SECURE WO ERS' C P SA ION COVERA IS LAWFUL, Nt5 SHALL UBJE TAN EMPLOYER TOC MINALPENALTIESAND CIVIL FINES UP TO ONE HUNDRE THOUSAND DOLLARS ($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY PG&E I hereby affirm that there is a construction lending agency for the performance of the work for which this INFORMATION permit is issued(Sec.3097,Civil Code). Lender's Name Address PG&E has asked that we notify all City/State Phone persons who will need new gas or electric service to consult them as to DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION proper location of both meters. 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 connection with work authorized by this permit, and that no building, structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36) As a reminder, PG&E and the feet high. (Chap.3.2,Grp.2,Art.2,Sec.341,Title 8,C.A.C.) telephone companies also recommend you make arrangements As owner-builder,I will not employ anyone to do work which would require a permit from the Division with them as early as possible to of Industrial Safety, as noted above, unless such person has a permit to do such work from the minimize delays in the connection of Division. your service. Division of Industrial Safety Permit No. 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating?, ero construction,and reby authorize !representati esofthi county to enter upon the above-meerty fo insp ti ur hQ Date G , Applicant l/ \/