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L CITY OF STOCKTON ~ �/� MUNITY DEVELOPMENT DEPARTMENT IE� IE U �:/ E D BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request 1 937-86E1560 {i jrpli% il a �}{i N(l i jii7Cr PERMIT G5 )Go'G5u i. U NSED CONTRACTORS DECLARATION `.i v JGvAddr ss ISSu L'alt: N WA6.NEF A4° 9jU9jG5 , - i f pirrl,it Type OUTSIDE CONNECTION----------2L _ It�ubdivisiorf ' Parcel Niir 159 02u 25 :.he �I 'Jll Ll�` 2r G1 G4 Ill G2 �V City of Stockton lty f� HL6 n L & LY � �f iF CUSTI NER RECEIPT � re, Owle'r Nagle ;UNTEF ; RA , se Address G�2 HWY 99 led_ nd Batch 1L: €i,jESUS 9fU9/K DS ,ne i ST�tKIuN CA rr, 9D215 F;eceiot no: 12546 1 Appl Type � OUTSIDE CONNECT aE41'E; To Sv Description at ale i Desc of pori FESIDENTIAE y ilrOftllt )es i %EWER LINE 21405 5373 BP BUILDING PERMIT 'Its !� Valuation G S 1, nt H fiquare ftp G �orin9 060 Q349,75 I Occup uroup .. --oast Type . sed Tender dt±tall dor e: CKRei#= 4€Sc`JE949.7� sed ll Sp:C1dI Notes and lUildli101S Total tendered: ! AN Eiii �uA �MENT PE 8349.7 RAI RE I,11RED PRIOR Total Fraywent: $2343.7 TO +N£O i IO'� TOi A �iTY AAIB T AlN101 Trans date: vq /35 Tine: 15:32:39 — UTILITY ' I TNI: IS A E'EFpII FOR THE COLLECVION OF. BUIdNUS HOURS: j AN - NOON, I SEWER CCINNE+-ilON FEES MLy, A 6,6IJGINO Pik - 5.PM i PERMIT DUST BE OBTAINED FROA THE %iiUNTY OF SAN IOAQUIN PRIOR TO THE lIon, 'I t.OMAINUAIENI OF UGlU _ Itten notice with the City Clerk's office within 90 days after appruva,.,,.,��e-oject i or Imposition of the fees,dedications,reservations or other exactions stating that the required payment is tendered or will be tendered when due,or that _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fany conditions which have been imposed are provided for or satisfied,under I protest,alongwith a statement of the actual elements of the dispute and the I F_AL'h I N FEE (""5%) �Ki 99.+ legal theory forming the basis for the protest. WORKER'S COMPENSATION DECLARATION 'I FF-11€W-EIi1 TiN:1-5)LAL W 400.00 I hereby affirm that l have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) I I F_ �_;�Uh B_ L A L t AJ '4,i 0 G.0 G Policy No. Company l ---------- ❑ Certified copy is hereby furnished.Expires ii El Certified copy is filed with the city building inspection department. F'E EI1 I i oTAI c c y li 9.I's Date ,Applicant ..i CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE � This section need not be completed if the permit is for one hundred dollars , f ($100)or less. !� I certify that in the performance of the work for which this permit is issued, shall not employ any person in any manner so as to become subject to the Workers' f Compensation Laws of California. Date Applicant `I NOTICE TO AP LEC NT:If,after making this Certificate of Exemption youshould ,�I become subject o th Workers'Compensation provisions of the Labor Code,you Ei must forthwith c ply ith such provisions or this permit shall be deemed revoked. I certify th t I read this applicatioa above information Ili is correct.I a o o ply with all icy a es and state laws refacing to hui} cc t tion,antl reby atives of this city toenteru boned pro rty t r es. SIGN pDORE;S ,� JOB ADDRESS 'I APPLICATION APPROVAL - THIS PERMIT DOES NOT BECOME VALID UNTIL SIGNED BY THE BUILDING Il OFFICIAL OR HlS DEPUTY AND FEES ARE PAID. y, SIGNATURE c