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CITY OF STOCKTON <br /> COMMUNITY DEVELOPMENT DEPARTN* <br /> BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 <br /> STOCKTON, CALIFORNIA 95202 24 Hr. Inspection RequeS' <br /> -q� 937-8560 <br /> PERMIT <br /> 11 <br /> E I I Applicaticla <br /> aper <br /> 000068 <br /> 06 <br /> * LICENSED CONTRACTORS DECLARATION <br /> mar w ja; ry Tewr <br /> Issue: bate <br /> Job Address <br /> 4125 WEST LN 1I08I07 <br /> a: .L <br /> Perwit Type . ; OUTSIDE CONHECTION.----------21 <br /> a,:yvx. n, Parcel Nbr 115 310 22 _ <br /> rr <br /> 4,M IF ae4 ton • Geo Code . : 1500 0.1 02 22 2 <br /> ECEI" It Owner Name . : LOPEZ RAMON k E IMEL <br /> Address . , . : 4152 IJARS RD <br /> "_;Datrh ID: NJESLI" 1108107 01 d STOCKTON CA 65210 <br /> "Receipt rlo: 13681 Appl Type , OUTSIDE CONNECT SEWER <br /> Type SwCd Descr;uti a Valuation 0 <br /> PwuD n# S4U7iE tt1 0 2onina . 012 <br /> 6;52 BP Daub Group : C66st Type , <br /> a <br /> 0 329,~•75 Special Notes and Conditions <br /> iendep tletail <br /> tl AN ENCROACHMENT PERMIT Is RE01kEO PRIOR <br /> EI: fe4N: i[[1 -41,75 TO CONNECTION TO A CITY MAINTAINED <br /> Total teiridered: 62949.75 UTILITY <br /> coal p3.Ynett; <br /> $2949.75 THIS IS A PERMIT FOR THE COLLECTION OF <br /> Tran; date; 11"OE/07 Time: 11:47:23 SEWER CONNECTION FEES ONLY. A BUILDING <br /> PERMIT MUST DE OBTAINED FROM THE COUNTY <br /> FU'S'Iikars HMUF'S, 9 AN - WON, I OF SAN JOAOUIN PRIOR TO THE <br /> PIT - 5F7 <br /> COMMENCEMENT OF YOkk <br /> OUTSIDE SEWER CONNECTION <br /> re <br /> servation or other exaction imposed on your prof yon .,.ulawglfn... <br /> once with the City Clark's offdl withlW90 days after approval of the protect _ _ - _ _ _ - - FEES - - - - - - - - - - - - - <br /> a ImpPSltlan of the fees;tledl¢ati.ns,rose~III he s or other exactions oblong <br /> find <br /> re I 'dpaymentistenderedorwool rtende'beorame'e,orthat IF-ADMIN FEE 13,551 ;K1 99,15 <br /> any Condf,ht swhich have bst imposed ere proeldad for or dapent... thuc vi TT <br /> pprotea[,Soongg with a statemem."tha recom 01amenls of me di3pNe and the .IF'WW"EXIaTdNs/-,alkAL ;AN ' 400 .00 <br /> legal theory loaning the basis Tor the Poorest <br /> WORKER'S COMPENSATION DECLARATION IF-WW'FUTURE'SI�AL ;AI 350.00 <br /> Thereby aXirtn tied i have acanncIoe of consent to spit-insure,or a ced'dinade 'I F'WW CON9"SICAL ;AJ 2`106'00 <br /> of Workers'Compensation Insurance,or a certified copy Hereof(Sec.3800,Lab.C.) <br /> Policy No. <br /> c.mparty PERMIT TOTAL 2,948,15 <br /> LlcemneatnpYIsnererr?ecrosned.rrp�lree_:. <br /> ❑ Certifiedoopy fa'91Ed!Mlh m.,c4ibuil�oV mspemlon deparbmnt. <br /> Dale Applicant - f I/ <br /> CERTIFICATE OFEXEMPTIQNFRGAI WORKERS-,COMPENSATION INSURANCE <br /> This section need not be completed H the Permit Is for one hundred dollars <br /> ($100)or less. -' <br /> centyfy that In the ped.ro a I of the w.M for wh ch this permit is Issued;l - -shallnotempl0 ~son Inany mannersotmiebecDma subjssto the Workers' <br /> Compen MCalalom— <br /> Date R, plicpnt <br /> _ I. <br /> TICE TO APPI, ff"moan¢ifris Certificate of Exempd in you should <br /> kcarne sublet"-3¢1"PA otkoTs' en5ation Provisions of also Labor Coale,you. <br /> Prowl IofthwfU compry tlh so <br /> muson pro -'4br this penpal shalt be deemed revoked. <br /> 10 ty. at ve read Nis ballon and¢tpale that the above information <br /> v{tlh aM cottyym�y ortlinencas end state laws <br /> e ng but dn,a 'a rczp"epmaeAJdbvbsof this dry ro: _ <br /> K s$ d �N <br /> e.er 1 v qie o ro dY r Inspection purposes. ' <br /> S NED - Pl]ORESS <br /> J A :. SSS <br /> "','MPLICATION APPROVAL <br /> 1 <br /> THIS PERMIT DOii ®ECOME VALID VNTIL SI(; E BY THE BUILDING , <br /> OFFICIALORHIS �P AND FEES ARE PAID. <br /> a a <br /> . rr.iAruaE - —Al '°z—�—,� <br />