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w/ CITY OF STOCKTON
<br /> COMUNITY.DEVELOPMENT DEPARTMENT
<br /> BUILDING DIVISION, CITY HALL PHONE:(209)937 85611,1
<br /> STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request
<br /> 9
<br /> PERMIT 937-8560
<br /> LICENSED CONTRACTORS DECLARATION Application Number00 00002321
<br /> I hereby affirm that I am licensed under provisions of Chapter 9(commencing
<br /> with Section 7000)of Division 3 of the Business and Professions Code,and my license
<br /> is in full force and effect. -"
<br /> �)I
<br /> CONTRACTOR Job Address Issue Date
<br /> 905 STOKES AV 5/04/00
<br /> LICENSE NO. c
<br /> LICENSE TYPE DATE—
<br /> STOCKTON BUS.LIC.NO.
<br /> ATE STOCKTONBUS.LIC.NO. Permit Type OUTSIDE CONNECTION----------21
<br /> HW
<br /> OWNER-BUILDER DECLARATION Subdivision .
<br /> I hereby allirm that I am exempt from the Contractor's License Law for the P a r c e) N b r 143 280 5 0 /
<br /> following reason(Sec.7031.5 Business and Professions Code:Any cityor county which
<br /> requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Geo Code 2600 01 03 01 4
<br /> its issuance,also requires the applicant for such permit to file a signed statement that
<br /> he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Owner Name BOVA ANTHONY J & PA
<br /> commencing with Section 7000)of Division 3 of the Business and Professions Code)or
<br /> that he is exempt therefrom and the basis for the alleged exemption.Any violation of Address . . , PO BOX 4175
<br /> Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
<br /> not more than five hundred dollars($500.): STOCKTON CA 95204
<br /> ❑ I,as owner of the property,or my employees with wages as their sole Appl Type , OUTSIDE CONNECT - SEWER
<br /> compensation,will do the work,and the structure is not intended or offered for sale D e$C O f work NON RESIDENTIAL
<br /> (Sec.7044).Business and Professions Code:The Contractor's License Law does not
<br /> apply to an owner of property who builds or improves thereon,and who does such work SEWER LATERAL T A P
<br /> 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 Valuation 0
<br /> year of completion,the owner-builder will have the burden of proving that he did not t
<br /> build or improve for the purpose of sale.) Square I t q 0 Zoning , . , 082
<br /> ❑ I, as owner of the property, am exclusively contracting with licensed Occup Group Const Type
<br /> contractors to construct the project(Sec.7044,Business and Professions Code:The
<br /> Contractor'sLicense Law does not apply to any owner of property who builds or
<br /> improves thereon,and who contracts for such projects with a contractor(s)licensed
<br /> pursuant to the Contractor's License Law.) Special Notes and Conditions
<br /> ❑ 1 am exempt under Sec. ,B&P.C.for this THIS IS TO COLLECT SEWER CONNECTION FEES
<br /> reason ONLY, A BUILDING PERMIT MUST BE OBTAIN-
<br /> Date o ED FROM THE COUNTY OF SAN JOAQUIN PRIOR
<br /> RETURN CHECK POLICY: I AM ARE IF MY CHECK IS RETURNED TO THE TO THE COMMENCEMENT OF WORK,
<br /> CITY,THIS PERMIT IS REVOKED.I AM ALSO AWARE,IF ANY WORK HAS BEEN
<br /> STARTED, THE CITY WILL IMPOSE AN INVESTIGATION FEE, (PER SMC 13-
<br /> 304(C))PLUS ANY OTHER REQUIRED FEES. - - - - - - - - - - - - - - FEES - - - - - - - - - - - - - - -
<br /> NOTE:To protest the imposition of any development fee,dedication,reservation IF-ADMIN FEE (3.5%) tK 1 243.03
<br /> or other exaction imposed on your project,you must file written notice with the
<br /> City Clerk's office within 90 days after approval ofthe project orimposition ofthe IF-WW-EXISTING-S/CAL #AH 1,100,00
<br /> fees, dedications, reservations or other exactions stating that the required
<br /> payment is tendered or will be tendered when due,or that any conditions which IF-WW-FUTURES/CAL tAI 962,50
<br /> have been imposed are provided for or satisfied, under protest, along with a
<br /> statement of the actual elements of the dispute and the legal theory forming the IF-WW-COMB-S/CAL $AJ 4 1881.25
<br /> basis for the protest.
<br /> WORKER'S COMPENSATION DECLARATION
<br /> I hereby affirm that I have a certificate of consent to self-insure,or a certificate PERMIT TOTAL 1 186.18
<br /> of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) 1
<br /> Policy No.
<br /> Company
<br /> ❑ Certified copy is hereby furnished.Expires
<br /> ❑ Certified copy is filed with the city building inspection department.
<br /> Date ,Applicant
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> This section need not be completed if the permit is for one hundred dollars
<br /> ($100)or less.
<br /> certify
<br /> I certify that in the performance or the work for which this permit is issued,I shall
<br /> not employ any person in any manner so as to become subject to the Workers'
<br /> Compensation Laws of California.
<br /> Dale Applicant i
<br /> NOTICE TO APPLICANT: 11, after making this Certificate of Exemption you should
<br /> become subject to the Workers'Compensation provisions of the Labor Code,you must
<br /> forthwith comply with such provisions or this pe mil shall be deemed revoked.
<br /> I certify Ihat I h e ad IN application and slate that the above information is
<br /> correct.I agree to c, re ly iall city and county ordinances and state laws r p6
<br /> building construction, n hereby authorize representatives of this city to enter n the
<br /> above m ned,pr e y for'nspection p rposes.
<br /> 9—
<br /> SIGN
<br /> JOB D E&6
<br /> APPLICATION APPROVAL
<br /> THIS PERMIT DOES NOT BECOME VALID UNTIL SIGNED BY THE BUILDING
<br /> OFFICIAL OR HIS DEPUTY AND E PAID.
<br /> SIGNATURE:
<br />
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