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DECLARATIONS„
<br />SPEC*RACTORS
<br />EXPIRATION
<br />LICENSEDDECLARATION
<br />INFORMATION
<br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of
<br />Division 3 of the Business and Professions Code, and my license is in full force and effect.
<br />Every permit issued by the Building
<br />License # Expiration Date
<br />Official under the provisions of this
<br />Date Contractor
<br />Code shall expire by limitation and
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />become null and void if the building or
<br />OWNER -BUILDER DECLARATION
<br />work authorized by such permit is not
<br />I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5,
<br />commenced within 180 days from the
<br />Business and Professions Code: Any city or county which requires a permit to construct, alter, improve,
<br />date of such permit, or if the building
<br />demolish, or repair any structure, prior to its issuance, also requires the applicantfor such permit to file a
<br />or work authorized by such permit is
<br />signed statementthat he is licensed pursuantto the provisions of the Contractor's License Law (Chapter 9
<br />suspended or abandoned at any time
<br />(commencingwith Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
<br />after the work is commenced for a
<br />therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
<br />period of 180 days. Work shall be
<br />per it subjects the applicantto a civil penalty of not more than five hundred dollars ($500.00).):
<br />considered abandoned if an
<br />as owner of the property, or my employees with wages as their sole compensation, will do the work,
<br />inspection has not been approved and
<br />\I,
<br />and the structure is not intended or offered for sale. (Sec. 7044, Business and Professions Code: The
<br />recorded within 180 days.
<br />Contractor's License Law does not apply to an owner of property who builds or improves thereon, and
<br />who does such work himself or through his own employees, provided that such improvementsare not
<br />intended or offered for sale. If, however, the building or improvement is sold within one year of
<br />completion, the owner-builderwill have the burden of proving that he did not build or improve for the
<br />purpose of sale.)
<br />Ell, as owner of the property, am exclusively contracting with licensed contractors to construct the
<br />INSPECTION
<br />project. (Sec. 7044, Business and Professions Code: The Contractor's ' w do not apply to
<br />INFORMATION
<br />an owner of property who builds or improves thereon, and who racts for such p ojects with a
<br />contractor/contractor(s) license pursuantto the Contrac 5s Lic se Law.)
<br />V
<br />F1 1 am exempt under Sec. the B siness an a ions Code for the
<br />The San Joaquin County Building
<br />Inspection Division has installed an
<br />followi rea
<br />automatic recording device to receive
<br />-
<br />Date Owner
<br />inspection requests. This service will
<br />be available 24 hours a day, seven
<br />WORKERS' SATIONDECLARATION
<br />days a week. Calls will be taken off
<br />I hereby affirm under penalty of perjury one of the following declarations:
<br />the recorder at 3:00 p.m. every
<br />F] I have and will maintain a certificate of consent to self-insurefor workers' compensation, as provided
<br />workday and distributed for
<br />for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
<br />inspectionthe following workday.
<br />issued.
<br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
<br />request an inspection, please call
<br />request
<br />Code, for the performance of the work for which this permit is issued. My workers' compensation
<br />(2 46$-3165. You will be requested
<br />(2
<br />to provide the following information:
<br />insurance carrier and policy number are:
<br />Carrier Policy Number
<br />1. Permit Number (Mandatory)
<br />(This section need not be completed if the permit is for one hundred dollars ($100) or less).
<br />2. Your Name
<br />I certify that in the performance of the work for which this permi . is ua all not employ any
<br />3. Job Site Address and Nearest
<br />iii person in any manner so as to become subject t orke ' m sati aws of California, and
<br />Cross Street
<br />agree that if I should become subject to the kers' c m ns do rovi ns of Section 3700 of the
<br />4. Telephone Number
<br />Labor Code, I shall forthwith comply with s 0vi ns.
<br />5. Day Inspection Preferred
<br />6. Type of Inspection
<br />Date) L� ( l — Appli
<br />WARNING: FAILURE TO SECURE S7MqNtWVERAGE IS UNLAWFUL, AND
<br />SHALL SUBJECT AN EMPLOYER T CR L PENALTIES PAD CIVIL FINES UP TO ONE HUNDRED
<br />THOUSAND DOLLARS ($100,000), 1 ITION TO THE COST OF COMPENSATION, DAMAGES AS
<br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
<br />CONSTRUCTION LENDING AGENCY
<br />PG&E
<br />I hereby affirm that there is a construction lending agency for the performance of the work for which this
<br />INFORMATION
<br />permit is issued (Sec. 3097, Civil Code).
<br />Lender's Name Address
<br />PG&E has asked that we notify all
<br />City/State Phone
<br />persons who will need new gas or
<br />electric service to consult them as to
<br />DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br />proper location of both meters.
<br />I hereby certify that no excavation five (5) or more feet in depth into which a person is required to
<br />descend, will be made in connection with work authorized by this permit, and that no building,
<br />structure, scaffolding,falsework, or demolition or dismantling thereof, will be more than thirty-six (36)
<br />As a reminder, PG&E and the
<br />feet high. (Chap. 3.2, Grp. 2, Art. 2, Sec. 341, Title 8, C.A.C.)
<br />telephone companies also
<br />recommend you make arrangements
<br />As owner -builder, I will not employ anyone to do work which would require a permit from the Division
<br />with them as early as possible to
<br />of Industrial Safety, as noted above, unless such person has a permit to do such work from the
<br />minimize delays in the connection of
<br />Division.
<br />ElDivision of Industrial Safety Perm it No.
<br />your service.
<br />I certify that I have read this application and state that above i orm o s co rect. ree to comply
<br />with all city and county ordinances and state laws ating to buil ing o truc on, a ereby authorize
<br />repres ntativespf this county to enter upon the ove- n pro for ' spe n purposes
<br />�j^ �� _[)q
<br />Date Appil
<br />
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