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calls JVAIi"'ll l-.all'.7 z Community Development Department Permit Number: q: -� to 1810 E.Hazelton Ave,Stockton,Ca 95205 Business Phone(209)468-3121 BP-1805107 Request For Inspection Phone(209)468-3165(24 Hour Recorder) \d�j ••• '� or on the web at sjgov.org _FQFt� LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Permit Address• 25920 N WATKINSON RD Division 3 of•the Business and Professions Code,and my license is in full force and effect. License�__---------------------___--Exp.Date_------- --------- Cross Street: COLLIER Date-------------------Contractor------------------------------------- City. ACAM OWNER-BUILDER DECLARATION Owners Name: XU KAIWEN&WANG YANLING I hereby affirm that I am exempt from the Contractor's License Law for the following reason. Phone: (Sec 7031 5.Business and Professions Code:Any city or county which requires a permit to construct, alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file 4 signed statement that he is licensed pursuant to the provisions of the Contractor's Applicant Name: KEITH GROSS WELLS&PUMPS License Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and Address: P O BOX 168 Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 5 by any applicant for a permit subjects the applicant to a civil penalty of City: LODI CA 95241 not more than live hundred dollars($500.00).) Phone: (339-4923 ) 17 1,as owner of this property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale.(Sec.7044,Business and Professions Code. The Contractor's License Law does not apply to an owner or property Contractor Name: KEITH GROSS WELLS&PUMPS 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, Address: P O BOX 168 however,the building or immprovement is sold within one year of completion,the City. LODI CA 95241 owner-builder will have the burden of proving that he did not build or improve for the e. . T: t r 2 Else of sale.) Stat a..c cnse: 848123 Exp: 1'1111/ 018 ,as owner of the property,am exclusively contracting with licensed contractors to construct Phone: ( 339-4923 ) the project.(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor/contractor(s)license pursuant to the Contractor's License Designer Name: Law) Address: 01 am exempt under Sec.__--__—_,of the Business and Professions Code for the following reason._ _—_ se#: --------------------------------------------- - License#: Date-- -------------Owner-------------------- ---------- Phone#: WORKERS'COMPENSATION DECLARATION I hereby afrnmi under penalty of perjury one of the following declarations: Scope of Work: SERVICE FOR AG PUMP 100AMPS F7I have and will maintaina certificate of consent to self-insure for workers'compensation, p a,provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Item Description Tot Fee F71 have and wll maintain workers'compensation insurance,as required by section 3700 of ___-_ ______________________________ _________ the Labor Code,for the performance of the work for which this permit is issued. My 1010 Imaging/Technology 15.00 workers'compensation insurance carrier and policy number are on file with the State 1019 Electrical Fee 100.00 Contractors License Board. 5030 General Plan Implement 5.00 OI certify that in the performance of the work for which this permit is issued 1 shall not employ any person in any manner so as to become subject to the workers'compensation laws of Califomta,and agree that if I should become subject to the workers'compensation Please see reverse side for important information. provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions Date _Applicant__ ---__-- — WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE:HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which Lilts penMri is issuou(S�a y7 7 y, Lender's Name--------------------------Address---------------------—_------ ■\�� !i I v li ll City/State -----------------Phone DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION 01 hereby certify that no excavation five(5)or more feet in depth into which a person is OCT U 7 20 In required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six (36)feet high (Chap.3.2,�P_o.Art.2,Sec 341,Title8,C.A.C.) 9' l 11anN n 0 As owner-builder,I will not employ anyone to do work which would require a permit from t !!! the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the Division. f7Division of Industrial Safety Permit No,-------------- -----_----_--_—__— I certify that I have read and state that the information given is correct. I agree to comply with all state laws and county ordinances relating to building construction,and authorize representatives of the Issuing Jurisdiction to enter upon the above-described property for inspection purposes. Signature of Legal Owner or Authorized Agent Date Applicant Accepted:JAA Approved:JAA Applied Date: 10/25/2018 Issue Date: 10/25/2018 API\:021-020-29 Valuation:$0.00 SgFt:0