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joe A,,aEss: 200 W Eaton Avenue, Tracy,CA 95376 Pin 0: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my licenses in full force and effect License 0 899451 Expiration Date 06/30/2021 Date 06/29/2007 Contractor Middle Earth Geo Testing, Inc. OWNER43UILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the follovnng reason(Section 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 License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt herefrom and the basis for the alleged exemption Any violation of Section 7031 5 by any applicant for a permit subjects the applicant to a cihnl penalty o`rot more than five hundred dollars(SSW)) ❑1. as owner of the property or my employees with wages as their sole compensation wig do the work and the structure is not intended or offered for sale(Section 7044, Business and Professions Code The contractors License Law does rot 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-bwlder will have the burden of proving that ne did not build or improve for the purpose of sale I ❑1 as owner of the property,am exciusryely contracting with licensed contractors to construct the project(Section 7044 Business and Professions Code(BdPC) 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 conlractof(s)licensed pursuant to the Contractor's License Law) ❑1 am exempt under Section BdPC for this reason Dab: Owner WORKERS'COMPENSATION DECLARATION I hereby affirm Etat I have a certificate of consent to self-Insure or a certificate of Workers Compensation Insuranceor a certified copy thereof(Section 3800. abor Code) Expiration Date Z Company Middle Earth Geo Testing, Inc. 0 Certihec copy is hereby fumished (Example provided.we can obtain a certified copy if needed) j ❑Certified copy is fled with the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE lTh,s section need not be completed if the permit a for one hundred w4lars fS1001 or less/ 1 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 Workers'Compensation Laws of California Dale: Applicant NOTICE TO APPLICANT II after making this Certificate of Exemption. you should become subject to the Workers Compensation provisions of the Labor Code,you must forthwith comply with such provisions or the permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which mus permit is issued(Section 3097, CPA Code) Lender's Name Lenders Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation rive (5) or more feet in depth into which a person is required to descend. wil be made in connection with work aulhonzed by the permit,and that no buddng structure,scaffolding,falsework.or demolition or dismantling thereof,will be more than thirty-six(36)feel high (Chapter 3 2.Group 2.Article 2.Section 341 Title 8,California Administrative Code) ❑ As owner-budder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety as noted above,unless such person has a permit to do such work from the division ❑Division of Industrial Safety Permit s I certify that I have read Pus application and state that the above information is correct I agree to comply with all city and county ordinances and state laws relating to well construction and or sewage system construction,and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Date Applicant EHD a3-C2+w' LICENSED CONMRACTORS DC0,AAA'n0N azsee