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' �f CITY OF TRACY � �]
<br /> TRACY PERMIT APPLICATION DEVELOPMENT AND ENGINEERING SERVICES
<br /> PART 1' .
<br /> 333 Civic Center Plaza,Tracy,CA 95376
<br /> Phone(209)831-6400
<br /> Fax No.(209)831-6439
<br /> BUILDJNG PROJECT IDENTIFICATION Inspection Request Line(209)831-6440
<br /> _ LICENSED CONTRACTOR DECLARATION-
<br /> APPLICATIbNlPERMIT NUMBER I hereby affirm under the penalty of perjury that I am licensed under provisions of Chapter 9(commencing
<br /> with Section 700q}ogf i�con 3 of the Business and Professions Code and.my lice t i f ll force and
<br /> 20500 HOLLY DR effect. Ct4A � lIs211
<br /> PROJECTLicense# License Class. Expiration Date
<br /> STREET
<br /> ADDRESS
<br /> j Contract c., f Date 1
<br /> APN T /0
<br /> / OWNE BUILDER ECLARATION-
<br /> DESCRIPTION OF WORK' (Sec-703IX Busine 'and Professions"Code t Any city which requires a permit to construct,alter,improve,
<br /> REMOVE 350 GAL;UNDERGROUIVD: demolish,or repair.any structure,prior,to;its.issuance,.also requires the applicant for such permit to file a
<br /> r TANK signed statement that he or she is licensed pursuant to the provision of the Contractors State License Law
<br /> y (Chapter0(commencing with Section 7000)of-Division 3 of the Business and Professions Code),or that he
<br /> of she is exempt,there from and'the b: is the alleged exemption.Any violation of Section 7031.5 by any
<br /> Applibant for a permit subjects tlie:applic Lot to a civil penalty of not more than five hundred dollars($500),I
<br /> hereby,'affirm;under'iie,penalty of peijury that I am exempt fro the Contractors License Law for the
<br /> PROPOSED USE'
<br /> reason(s):indieated,below by tiie checkmarks(s)I;have placed next to.the applicable item(s).
<br /> OR OCCUPANCY
<br /> _I;as owner of the property or my employees with wages as their sole compensation,will do() I of or
<br /> w, * (.)-portions of. the work,-and the structure is not intended or offered-for sale(Sec. 7044, Business and
<br /> VALUATION' S 5,000.00 'Professions Code.The Cohtraclors.License Law does not apply to an owner of property who builds or
<br /> OF PROJECT h improves hereon,and who'does such work himself or herself or through his or her employees,provided that
<br /> such ith rovem
<br /> OWNER p ents are not-`.intended or offered for sale.If,however,the building or improvement is sold
<br /> ' within one year.of completion the ownerbuilder will have the burden of proving that he or she did not build
<br /> or improve for the ptirpose of s1.ale)gq�_.ti,'• -
<br /> n I;'as owner of the property aM�exelusively contracting with licensed contractors to construct.the project
<br /> a - (Sec.7044.Business and'Professions Code The Contmctois License Law does not apply to an owner of the
<br /> property who builds or improves ih'eremi and who contracts for such projects with a contractor(s)licensed
<br /> PHONE FAX. J pursuant,to the.Contractors License Law.)
<br /> JIM THORPE OIL
<br /> e141CONTRACTOR _I am exempt'under Sec. Business and Professions Code for this reason.
<br /> F. 351 N BECKMAN RDiL.
<br /> r'. CA _ `.'95241, Owner
<br /> LODI }s
<br /> Date
<br /> I' WORKERS'COMPENSATION DECLARATION-
<br /> 7e (209)329-54$1 hhereb affirm under penalty of er u one of following declarations.
<br /> PHONE p,qX Y. , P h' P J ri'• g
<br /> STATE LICENSE NUMBER A 0:495699
<br /> 1.have and will maintain corkers'compensation insurance,as required by Section 3700 of the Labor
<br /> CITY BUSINESS LICENSE NUMBER 37205Code,for the perform arise of the work for which this permit is issued.My workers'compensation insurance
<br /> ENGINEER pr ARCHITECT carrier and policy number are.(This section need not be completed if the'permit is for one hundred dollars
<br /> Or less),
<br /> less)
<br /> STATE COMP FUN] 1671173 1/7/2012
<br /> - k Cartier. Policy Number - Expiration Date
<br /> I certify that in the.performance of the work for which this permit is issued,I shall not employ any
<br /> person in any manner so as to become subject to the workers'compensation laws of California,and agree
<br /> PHONE FAX that if I should become subject to the workers`compensation provisions of Section 3700 of the Labor Code,I
<br /> APPLICANT shall forthwith comply w'ih those rovissgyu
<br /> Applicatak Da1
<br /> te 2.
<br /> WARNII FU URE TO CURE W KERS' COMPENSATION COVERAGE IS UNLAWFUL,
<br /> AND kiALL SU JECT AN EMPLOY! TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
<br /> HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION.
<br /> PHONE FAX DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
<br /> ATTORNEY'S FEES.
<br /> I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND.STATE
<br /> THAT THE SHOWN INFORMATION IS CORRECT,AND rHAT.I AM -CONSTRUCTION LENDING AGENCY-
<br /> THE OWNER*OR DULY.AUTHORIZED AGENT**OF THE OWNER. Applicant-affirms under the penalty of perjury that there is a construction lending agency for the
<br /> I AGRERTO COMPLY WITH ALL CITX AND STATE LAWS performanceof the work for whicli the perriit .is issued (Section 3097, Civ. C) Lender's
<br /> RELATING TO BUILDING CONSTRUCTION: 11-HEREBY Name Address
<br /> AUTHORIZE REPRESENTATIVES OF THE CITY OF..TRACY TO'
<br /> ENTER THE ABOVE MENTIONED PROPERTY.FOR INSPECTION P pplicant.affimis under.ihe penalty of perjury that there is no construction-lending agency for the
<br /> performance of the work.for which.the permit is issued(Section 3097,Civ.C)
<br /> PURPOSES.*Requires separate verification f6rmi` **requi'res,separatc,
<br /> authorization form., ^�^' a _IMPORTANT-
<br /> Applicattori;is hereby made to the City of Tracy Department of Development and Engineering Services for a
<br /> SIGNATURE x. pe.unit subject to the condgion'and restrictions set forth on this application,and all applicable city and state
<br /> and'obtimances.
<br /> 1':Each ersonu on•whose behalf this application is made and each person at whose request and for whose
<br /> PRINT N P P pP P q
<br /> =benefit work is.performed under'or pursuant to,any.permit issued as a result of this application agrees to,and
<br /> shall,indemnify and hold harmless the City of Tracy,its officers,agents and employees in accordance with
<br /> DATE '�. �f�J' all applicable city and state laws and ordinances.
<br /> 4 OWNER* CONTRACTOR 2.Any P1anRevie"becomes nuIl'and void afier:ONE HUNDREI]EIGHTY(l'g0)days from the date of chis
<br /> .. - - .application.
<br /> O AGENT-FOR OWNER** AGENT TOR CONTRACTOR
<br /> C- VED BY DATE NOTE; A VALID PERMIT RESULTS WHEN PART II IS ISSUED BY THE CITY OF TRACY
<br /> 7-1k a_tl,+ AD DEPARTMENT OF DEVELOPMENTAND ENGINEERING SERVICES.
<br /> •, - - -- .. March 2K9
<br />
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