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CITY OF TRACY DEVELOPMENT AND ENGINEERING SERVICES , ;: PERMIT APPLICATION 333 Civic Center Plaza,CA 95376 PART I one(209)831-6400 Fax hNo.(209)831-6400 Inspection Request Line(209)8316440 BUILDING PROJECT IDENTIFICATION ,LICENSED CONTRACTORDECLAR477ON- APPLICATION/PERMIT NUMBER 19-2983 I hereby affirm under the penalty of pequry that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect License# License Class: Expiration Date: STREET ADDRESS: 28087 S LAMIAERS RD Contractor Date APN:25105006 DESCRIPTION OF WORK ADDDING TOILET&SINK X1.1 S �W -OWNER BUIIDERDECLAR477ON- PROPOSED USE OR OCCUPANCY: (Sec 7031.5 Business and Professions Code)Any city which requires a permit to construct,alter,improve,demolish,or repair any structrue prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provision of the Contractors State License Law(Chaper 9(commencing with Section 7000) VALUATION OF PROJECT:3000 of Division 3 of the Business and Professions Code),or that he or she is exempt there from 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 not OWNER more than five hundred dollars($500).I hereby affrm under the penalty of perjury that I am exempt from the Contractors License Law for the reason(s)indicated below by the checkmarks(s)I have placed next to the applicable items(s). VASUDEVAN,MUDALODU V I as owner of the property,or my employees with wages as their sole compensation,will do()all of or PHONE: FAX: ()portions of the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code. The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or bar employees,provided that such improvements are not intended or offered for CONTRACTOR' sales.I&however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for the purpose of sale.) OWNER BUILDER I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044. Business and Professions Code.The Contractors License Law does not apply to an owner of the property who builds or PHONE: FAX: improves thereon,and who contracts for such projects woth a contractor(s)licensed pursuant to the Contractors License Law.) STATE LICENSE NUMBER' I am exempt under�ea Business and Professions Code for this reason CITY BUSINESS LICENSE NUMBER: owner.V Dat° ENGINEER OR ARCHITECT: -Wo ERS'C�-- O=Jf)ECLAR4TION- herebyaffthe following declarations. I have and will maintain worker's compensation insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued.My workers'compensation insurance carrier and policy number PHONE: FAX: are:(This section need not be completed if the permit is for one hundred dollars($100)or less) Carrier Policy_Number Expiration Date I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any APPLICANT: manner so as to become subject to the workers'compensation laws of California,and agree that if I should become subject to the worker's compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with those VASUDEVAN,MUDALODU V provisions. Applicant Date PHONE:2095977984 FAX: I CERTIFY THAT I HAVE READ THIS APPLICATION WING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CMI.FINES UP TO ONE HUNDRED AND STATE THAT THE SHOWN INFORMATION IS THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION DAMAGES AS CORRECT,AND THAT I AM THE OWNER*OR DULY PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. AUTHORIZED AGENT**OF THE OWNER I AGREE TO COMPLY WITH ALL CITY AND STATE LAWS -00NS7RUC77ONLENDINGAGENCY- RELATING TO BUILDING CONSTRUCTION.I HEREBY AUTHORIZE REPRESENTATIVES OF THE Applicant.affirms under the penalty of perjury that there is a construction lending agency for the performance of the work for which the permit is issued(Section 3097,Civ.C)Lender's CITY OF TRACY TO ENTER THE ABOVE Name Address MENTIONED PROPERTY FOR INSPECTION PURPOSES. *Requires se arate Verification form. Applicant affirms under the penalty of perjury that there is no construction lending agency for the performance of the **requires separate ationf76 . work for which the permit is issued(Section 3097,Civ.C) th IMPORTANT- SIGNATURE Application is hereby made to the South San Joaquin County Fire Authority's Community Risk Reduction Division for a PRINT N permit subject to the condition and restrictions set forth on this application,and all applicable city and state laws and -n ordinances. DATE (% / LEach person upon whose behalf this application is made and each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application agrees to,and employees in accordance with all applicable city and state laws and ordiances. ❑ OW R* /DCONTRACTOR 2.Any Plan Review becomes null and void after ONE HUNDRED EIGHTY(I80)days from the date of this application. ❑ AGENT FOR D AGENT FOR NOTE:A VALID PERMIT RESULTS WHEN PART H IS ISSUED BY THE SOUTH SAN JOAQUIN COUNTY OWNER** CONTRACTOR FIRE AUTHORITY COMMUNITY RISK REDUCTION DIVISION. RECEIVED BY: DATE: U— —