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- t San Joaquin County
<br /> a•4 . , ;.'. ";� Community Development Department Permit Number:
<br /> 1810 E.Hazelton Ave,Stockton,Cs 95205
<br /> Business Phone(209)468-3121 BP-1704835
<br /> Request For Inspection Phone(209)468-3165(24 Hour Recorder)
<br /> •jj;t' or on the web at sjgov.org
<br /> O
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section 7000)of permit Address: 11851 W VALPICO RD
<br /> Division 3 of the Business and Professions Code,and my license is in full force and effect.
<br /> License k Exp.Date Cross Street: CORRAL HOLLOW
<br /> Date Contractor City: TRAC
<br /> OWNER-BUILDER DECLARATION Owners Name: PENA,AURORA
<br /> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. Phone:
<br /> (Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,
<br /> alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for
<br /> such permit to file o signed statement that he is licensed pursuant to the provisions of the Contractor's Applicant Name: PENA,AURORA
<br /> License Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any Address: 1 1851 W VALPICO RD
<br /> violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of City: TRACY CA 95376-9124
<br /> not mKre than five hundred dollars($500.00).):
<br /> I,as owner of this property,or my employees with wages as their sole compensation,will do Phone:
<br /> the work,and the structure is not intended or offered for sale.(Sec.7044,Business and
<br /> Professions Code: The Contractor's License Law does not apply to an owner or property Contractor Name:
<br /> who builds or improves thereon,and who does such work himself or through his own
<br /> employees,provided that such improvements are not intended or offered for sale. If, Address:
<br /> however,the building or immprovement is sold within one year of completion,the City.
<br /> owner-builder will have the burden of proving that he did not build or improve for the
<br /> se oC sale.) State License: Exp:
<br /> 51,as owner of the property,am exclusively contracting with licensed contractors to construct Phone:
<br /> the project.(Sec.7044,Business and Professions Code: The Contractor's License Law does
<br /> not apply to an owner of property who builds or improves thereon,and who contracts for
<br /> such projects with a contractor/contractor(s)license pursuant to the Contractor's License Designer Name:
<br /> Law.) Address:
<br /> 711 am exempt under Sec. oC Business and Professions Code for the
<br /> following reason: City.
<br /> Date (Zt'u 7 o License#:
<br /> Phone#:
<br /> WORKERS'C P SATTON DECLARATION
<br /> I hereby affirm under penalty of perj ne of th following declarations: Scope Of Work: FRAME IN 2 STORAGE CLOSETS
<br /> [have and will maintain a cenif etc of cons rt to self-insure for workers'compensation,
<br /> as provided for by section 3700 f the Labor e,for the performance of the work for AND INSULATE EXISTING GARAGE AT
<br /> which this permit is issued. —/ SFR
<br /> I have and will maintain wor ers'compensation insurance,as required by section 3700 of
<br /> the Labor Code,for the pe
<br /> mance of the work for which this permit is issued. My
<br /> work s'compensation incur acarrierandpolicynumberareonfilewittCtheState Item Description TOC Fer?
<br /> Co actors License Board. ----- ------------------------------ ---------
<br /> I certify that in the perform ce of the work Cor which this permit is issued,I shall not 1000 Building Fee 100.00
<br /> employ any person in any manner so as to become subject to the workers'compensation laws 1010 Imaging/Teehnol ogy 15.00
<br /> ofCalifomia,and agree that if 1 should becom b ect to the workers'compensation 5030 General Plan Implement 5.00
<br /> provisions of Section 3700 of the Labor ode, a I fo wi ply with thea
<br /> provis
<br /> Date r �t- Applican Please see reverse side for important information.
<br /> WARNING:FAILURE TO SECURE W RS'CO ENSATION COVERAGE IS
<br /> UNLAWFUL AND SHALL SUBJECT E PLOYER TO CRIMINAL PENALTIES AND
<br /> CIVIL FINES UP TO ONE HUNDRED O DOLLARS(5100,000),IN ADDITION
<br /> TO THE COST OF COMPENSATION, AMAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTEREST, ATTORNEYS FEES.
<br /> CONSTRU ON LENDING AGENCY
<br /> I hereby affirm that there is a constructi lending agency for the performance of the work for which
<br /> this permit is issued(Sec.3097,Civil C e).
<br /> Lender's Name__ Address
<br /> City/State_ Phone
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> f hereby certify that no excavation rive(5)or more feet in depth into which a person is
<br /> required to descend will be made in connection with work authorized by this permit,and that
<br /> no building,structure,scaffolding,fakework or demolition or dismantling thereof,will be
<br /> more an thirty-six (36 )fat high.(Chap.3.2,Grp.2,Art.2,Sec.341,TitleB,C.A-C.)
<br /> t /I"s owner-builder,I will not employ anyone to do work which would require a permit from
<br /> the Division of Industrial Safety,as noted above,unless such person has a permit to do such
<br /> work from the Division.
<br /> F7 Division of Industrial Safety Permit No.
<br /> I certify that I have read and state that the information given is correct. I agree to comply with all
<br /> state laws and county ordinances relating toI wctior and authorize representatives of
<br /> the Issuing Jurisdiction to enter upon the ajlKe-describelf property for inspection purposes.
<br /> Signature ofLfgal Owner or Aut d Agen
<br /> 21(
<br /> Date [ `—(I Appllcan
<br /> Accepted:JAA Approved:J I
<br /> A lied Date: 12/04/2017 Issue Date: 12/04/2017 APN:242-050-04 Valuation:$0.00 SgFt:0
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