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<br /> SPECIFI DECLARATIONS EXPIRATION
<br /> LICENSED COIWCTORSDECLARATION INFORMATION
<br /> I hereby affirm that I am licensed under the pr isions of Chapter 9 (commencing with Section 7�)of
<br /> Division 3 of the Business and Professions Code,and my license is in full force and effect Every permit Issued by the Building
<br /> License# Expiration Date Official under the provisions of this
<br /> Date Contractor Code shall expire by limitation and
<br /> become null and void if the building or
<br /> OWNER-BUILDER DECLARATION work authorized by such permit is not
<br /> 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Sec.7031.5, commenced within 180 days from the
<br /> Business and Professions Code:Any city or county which requires a permit to construct,alter,improve, 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 or work authorized by such permit is
<br /> signed statementthat he is licensed pursuantto the provisions of the Contractors License Law(Chapter9 suspended or abandoned at any time
<br /> (commencingwith Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt 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 period of 180 days. Work shall be
<br /> permi jects the applicant to a civil penalty of not more than five hundred dollars($500.00).): considered abandoned if an
<br /> 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
<br /> and the structure is not intended or offered for sale. (Sec.7044,Business and Professions Code: The 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 improvements are 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 /> 1, as owner of the property,am exclusively contracting with licensed contractors to construct the INSPECTION
<br /> project. (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to INFORMATION
<br /> an owner of property who builds or improves thereon,and who contracts for such projects with a
<br /> contractor/contractor(s)license pursuantto the Contractor's License Law.)
<br /> I am exempt under Sec. of the Business and Professions Code for the The San Joaquin County Building
<br /> Inspection Division has installed an
<br /> following rpaso automatic recording device to receive
<br /> Date Owr inspection requests. This service will
<br /> WORKERS' MPENSATIONDECLARATION be available 24 hours a day, seven
<br /> days a week. Calls will be taken off
<br /> I hereby affirm under penalty of perjury one of the following declarations: the recorder at 3:00 p.m. every
<br /> ElI have and will maintain a certificate of consent to self-insure for workers'compensation,as provided workday and distributed for
<br /> for by Section 3700 of the Labor Code,for the performance of the work for which this permit is inspection the following workday.
<br /> issued.
<br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor To request an inspection,please call
<br /> (209)468-3165. You will be requested
<br /> Code,for the performance of the work for which this permit is issued. My workers'compensation to provide the following information:
<br /> insurance carrier and policy numberare:
<br /> Carrie Policy Number 1. Permit Number(Mandatory)
<br /> (T • section need not be completed if the permit is for one hundred dollars($100)or less). 2• Your Name
<br /> I 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
<br /> person In any manner so as to become subject to the workers'compensation laws of California,and Cross Street
<br /> agree that if I should become subject to the workers'compensation provisions of Section 3700 of the 4. Telephone Number
<br /> Labor Code,I shall forthwith comply with those pr visions. 5. Day Inspection Preferred
<br /> 6. Type of Inspection
<br /> Date � �/�'�"r;./ / Applicant. �.i-v �
<br /> WARNINAILURE TO SECURE WO E OMPEN ATION COVERAGE IS UNLAWFUL, AND
<br /> SHALL SUBJECT AN EMPLOYER TO CRI INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
<br /> THOUSAND DOLLARS ($100,000),IN ADDITION 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 PG&E
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this INFORMATION
<br /> permit is issued(Sec.3097,Civil Code).
<br /> Lender's Name Address
<br /> City/State Phone PG&E has asked that we notify all
<br /> persons who will need new gas or
<br /> electric service to consult them as to
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 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 /> str re,scaffolding,falsework,or demolition or dismantling the reot,will be more than thirty-six(36) As a reminder, PG&E and the
<br /> et high. (Chap.3.2,Grp.2,Art.2,Sec.341,Title 8,C.A.C.) telephone companies also
<br /> recommend you make arrangements
<br /> As owner-builder,l will not employ anyone to do work which would require a permit from the Division 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 minimize delays in the connection of
<br /> Division. your service.
<br /> ElDivision of Industrial Safety Permit No.
<br /> I certify that I have read this application and state that the above information is correct. 1 agree to comply
<br /> with all city and county ordinances and state laws relating to building construction,and hereby authorize
<br /> representatives of this county to enter upon the above-met(t�lionedproperty for ins ction purposes.
<br /> Date ©' Applican " L,
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