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COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION,CITY HALL PHONE:(209)937-8561 ,%WW STOCKTON,CALIFORNIA 95202 *.I 24 Hr. inspection Request • 937-8560 PERMIT LICENSED CONTRACTORS DECLARATION t hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full lorceand eHect. Application Number CONTRACTOR 99 00001079 LICENSE NO. LICENSE TYPE DATE STOCKTON BUS.LIC,N0. Job Address Issue Gate OWNER-BUILDER DECLARATION 1565 N BROADWAY AY 3129199 1 hereby affirm that I am exempt tram the Contractor's License Law for the following reason(Sac.7031.5 Business and Processions Code:Any city or County which requires a permit to construct,alter.Improve,demolish,or repair any structure,prior to ds issuance,also requires the applicant for such permit to file a signed statilil that Permit Type . OUTSIDE CONNECTION----------2L he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Subdivision , comirenemg with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis lot the alleged exemption,Any violation of Parcel Nbr 113 150 22 Section 7031.5 by any applicant for a permit subjects the applicant to a tide penalty of C not more than live hundred dollars($500.): Geo Code 1700 02 02 05 2 ❑ 1,as owner of the property,or my employees with wages as their sole Owner Name compensation,will do the work-and the structure is not intended Or offered for sale (Sec.7044).Business and Professions Code:The Contractors License Law does not Address r apply to an Owner of property who builds or Improves thereon,and who does such work hlmse8 or through his own employees, provided that such Improvements are not Intended or offered lot sale.If,however,the budding or improvement is sold within one year of completion.the owner-builder will have the burden of proving that he did not App I Type OUTSIDE CONNECT - SEWER build or improvelorthepurposeofsale.) Desc of Work ; RESIDENTIAL ❑ I, as owner at The property, am exdustvaly contracting with licensed SEWER LINE contractors to construct the prolan(Sec.7D44,Business end Professions Code:The Contractor's License Law does not apply to any owner of property who builds or valuation D Improves thereon. and who contracts for such projects with a conlrector(s)licensed pursuant lb the Contractor's License Law.) Square ftg 0 Zoning . . . 092 ❑ 1 am exempt under Sec. 66 P.C.for this Occup Group Const Type reason Date Owner Special No es and Conditigns RETURN CHECK POLICY: 1 AM AWARE IF MY CHECK IS RETURNED TO THE PROJ; THIS IS A PERMIT FOR CONNECTION CITY.THIS PERMIT IS REVOKED.I AM ALSO AWARE.IF ANY WORK HAS BEEN STARTED, THE CITY WILL IMPOSE AN INVESTIGATION FEE, (PER SMC 13- FEE COLLECTION ONLY, A BUIDING PERMIT 311kill PLUS ANY OTHER REQUIRED FEES. MUST BE OBTAIHEG FROM THE COUNTY OF NOTE:To protest the Imposition of any development Ise,dedication,reservation or other exaction Imposed on your project,you must life written notice with the SAN JOAQUIN PRIOR TO THE COMMENCEMENT City Clerk's office within 90 days altar approval of the project or Imposition of the lees, dedications, reservations or Other exaction* stating that the required OF WORK, payment is tendered or will be tendered when duo.or that any conditions which have been imposed are provided for or satisfied. under protest.along with a statement of the actual elements of the dispute and the legal theory forming the - - - - - - - - - - - - - - FEES - - - - - - - - _ - - - - - - basis for 4119 pratfall WORKER'S COMPENSATION DECLARATION A05-IMPACT FEES(ATTACHED) 3924.10 1 hereby affirmthat i have a Certificate 01 consent to sell-insure.Or a certificate of worxersCompensation Insurance.or a certified copy thereof(Sec.3800,Lab.C.) --------- POBCy NoPERMITTOTAL 3924.10 Company ❑ Candled copy is hereby furnished.Expires ❑ Certified copy Is tiled with the city building Inspection department. Date ,Applican[/ CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be completed If the permit is for one hundred dollars 15100)or less. I cerllty that In the performance at the work for which this permit Is Issued.I Shall not employ any person In any manner so as to became subject to the Workers' Compensation Laws of Caldornla. Date Applicant NOTICE TO APPLICANT 11, after making this gertiticate of Exemotl you should become subjec<WorkersCompe55i��vsions rs-Comps visions of the Lab ode.you must forthwith complovisl permit shall be deem r aked. f Cerldythis application and state the ove Information Is correct I agreeith all❑ty and county or I es and tate laws relating tobudding Constreby authonza repres Ives o Is dy Io enter upon the above r m Ion purpos I D ADDRESS ,OB ADDRESS APPLICATION APPROVAL THIS PERMIT DOES NOT BECOME VALID UNTIL SIGNED BY THE BUILDING ^FFiC1AL C IS DEPUTY /� AND FEES ARE PAID.