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1550 C Drive,Trac CA 95376 Joe ADDRESS: Cypress Y� PERMIT N: 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 license is in full force and effect License 0 899451 Expiration Date 06/30/2021 Date 06/29/2007 Contractor Middle Earth Geo Testing, Inc. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Lew for the following reason(Section 7031.5.Business and Professions Code. Any city or county which requires a permit to construct.eller 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 Contractors 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 violaton of Section 7031 5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500)1 ❑ I as owner of the property.or my employees with wages as their We compensation, will do the work and the structure Is not intended or offered for sale(Section/7044.Business and Professons Code The contractors License Law does riot 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 h owerver, the budding 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 wth licensed contractors to construct the project(Section 7044 Business and Professions Code(B&PC) The Contractor's License Law does rot apply to an owner of property who b odds or improves hereon. and who constructs for such projects wmh a contraaorls)licensed pursuant to the Contractors License Law-) ❑1 am exempt under Seaton BSPC for this reason - Dab: Owner i WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers Compensation Insurance or a certified copy thereof(Section 3800.Labor Code) Expiration Date 2, 6.21 Company Middle Earth Geo Testing,Inc. o Certified copy is hereby furnished (Example provided.we can obtain a certified copy if needed) ❑Certified copy is flea wrath the Environmental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE tTh s section need not be completed it pie permit is for one hundred dollars(51001 or less) 1 ceruty 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 Dab: Applicant NOTICE TO APPLICANT If after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code.you mus,forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that mere is a construction lending agency for the performance of the work for which this permit Is issued(Section 3097 Civil Code) Lenders Name Lenders Address DMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ❑ 1 hereby certify that no excavation five(51 or more feet in depth into which a person is required to descend, will be made in connection with work auUlxized by the permit.anm d that no budding structure.scaffolding.falsework.or demolition or Ctsantling thereof.will be more than thety-six(36)feet high (Chapter 32.Group 2.Article 2,Section 341,Title 8.California Administrative Code) ❑ As owner-builder.I will not employ anyone to do work which would require a permit from the Dw3ton of Industrial Safety.as noted above,unless such person has a pemnl to do such work from the division ❑Division of Industrial Safety Permit M I cemfy 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 to well construc9on end or sewage system construction.and hereby authorize representatives of this county to enter upon the above-mentioned property for inspemn purposes. Date Applicant EMD+3-02007 LICENSED CONTRACTORS DECLARATION 6.26-09