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'--•� ' o� San Joaquin County
<br /> Community Development Department 1 ;< �' p p Permit Number:
<br /> 1810 E.Hazellon Ave,Stockton,Ca 95205
<br /> + Business Phone(209)468-3121 BP-1801417
<br /> Lq _ `p Request For Inspection Phone(209)468-3165(24 Hour Recorder)
<br /> L Li"L". fit or on the web at ajgov.org
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under provisions or Chapter 9(commencing with Section 7000)or permit Address: 18373 SMAC ARTHUR DR
<br /> Division 3 of the Business and Professions Code,and my license is m full force and effect.
<br /> License k _ _ _ Exp Date _____ _ Cross Street: W DELTA
<br /> Date-- ---- _-Contractor— ------ __-- -- City. TRAC
<br /> OWNER-BUILDER DECLARATION Owners Name: RAFAEL GONZALEZ
<br /> 1 hereby affirm that I am exempt from the Contractors License Law for the following reason Phone: 650-924-3086
<br /> (Sec.7031.5,Business and Professions Code.Any city or county which requires a permit to construct,
<br /> alter,improve,demolWi,or repair any structwe,prior to its issuance,also requires the applicant for
<br /> SLC
<br /> permit to file a signed statement that he is liccsed pursuant to the provisions ofthe Coriractors Applicant Name: RAFAEL GONZALEZ
<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: 18373 S MACARTHUR DR
<br /> violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of C1Iy. TRACY,CA 95304
<br /> not more than five hundred dollars($500.00).): Phone: 650-924-3086
<br /> F7 I,as owner of this property,or my employees with wages as their sole compensation,will do
<br /> the work,and the structwe is not intended or offered for sale(Sec 7044,Business and
<br /> Professions Code, The Contractors License Law does not apply to an owner or property COntIaclor Nallm:
<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 completiom the City
<br /> owner-builder will have the burden of proving that he,did not build or improve for the
<br /> se of sale) State License: Exp:
<br /> 1,m owner of the property,am exclusively contracting with licensed contractors to construct Phone:
<br /> the project.(Sec.7044,Business and Professions Code. The Contractors 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 Contractors License Designer Name:
<br /> Law) Address:
<br /> 1 am exempt under See. of the Business and Professions Code for the
<br /> following reason____ — ---- -- City.
<br /> License#:
<br /> Date
<br /> ----- ---Owner--- Phone#:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> Ihereby affiirmunder penaltyofperjury one ofthefollowing declaratiors' SCO of Work GRADING FOR LAND LEVELING
<br /> L have and will maintain a certificate of consent to self-i swe for workers'compensation,
<br /> as provided for by section 3700 of the Labor Code,for the performance of the work for
<br /> wtuchthis permitisissued Item Description Tot Fee
<br /> f7I have and will maintain workcrs'comperostion tnuuancc.as required by section 3700 of
<br /> ----- ------------------------------ ---------
<br /> the Labor Code,rot the performance of the work for which this permit is isstxd My 900 Plan Check Fee 4S.00
<br /> workers'compensation insurance carrier and policy number are on file with the State 1000 Building Fee 271.45
<br /> Contractors License Board, 1009 Plot Plan Review 50.00
<br /> 1 certify that in the performance of the work for which this permit is issued,I shall not 1010 Imagi n /Teehnol oqy 15.00
<br /> employ any person in any mamw so as to become subject to the workers compcuation laws 5030 General Plan Imp ement 13.57
<br /> of California,and ag ee that if I should become subject to the workers'compensation
<br /> provisions of Section 3700 of the Labor Code,1 shall forthwith comply with these
<br /> ons
<br /> Date Please see reverse side for important information.
<br /> Date _ _ Applicant
<br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1S
<br /> UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
<br /> I CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION
<br /> TOTHE HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the perfbmwcc of the work for which
<br /> this permit is issued(See 3097,Civil Code)
<br /> Lenders Name Address
<br /> City/State_____.__-- --
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> OI hereby certify that no excavation five(5)or more feel 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 falsework,or demolition or dismantling thereof,will be
<br /> more than thirty-sit(36)feet high(Chap 3 2,Grp.2,Art 2,Sec 341,Tidell,C A C J
<br /> QAs owner-builder,1 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 /> ODivision of Industrial SafetyPernut No
<br /> 1 certify that 1 have read and state that the information given is correct. I agree to comply with all
<br /> state laws and county ordinances relating to building construction,and authorize representatives of
<br /> the Issuing Jurisdiction to enter upon the above-described property for tnupection purposes
<br /> Signature of Legal Owner or Authorized Agent
<br /> Date Applicant
<br /> Accepted:JAA Approved:DH Applied Date:04/10/2018 Issue Date:0426/2018 APN:213-020-52 Valuation:$0.00 SgFt:0
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