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APPLICATION FOR BUI G PERMIT INSTRUCTIONS: Use bo 'alit pen or hard pencil. Press firmly, no erasures. CITY OF TRA A double lee will be d for work commenced before permit is issued. BUILDING INSPECTION DEMMMENT Type of permit low Owner/Occupant ❑ Regular ❑ 835-2211 ExMnsion 52 Department use only Street Address of Job �........11 .._.wl ee..r............. Plans Submitted Calcs Submitted ..................o�.r.3 :.....1c1��.7:,a ..................ti i Received by Date Legal Description, Loris) . Block ................ ........................................................... VALIDATION $ �/ ......... ..........I...........................r-.._...._.........._.....I....�................................_... /rtDescription of Work- ....... Permit Fee 5................. `f.J.f q �..4.. _......_./.Q.r h?ou: ,....-Ge..._•7..- '_1.L7.f.�.S........ Penalty lif applicable) 5..... New_.. Addition...._. Alteration...... Repair...... Demolish_..L.-Ifelocate..._.. Size Building.............. ............Sq.Ft. No. Bedrooms............No.of Units............ Plan Check Fee 5........................... . Area of lot.....................:......--. Date recorded.................................................. Capital Improvement S.............................. uu TT OWNER, ... cQC..�L'1.L. 5........................ ...Dwelling Units rs $75.00 ADDRESSt- q C+ PARK ACQUISITION FUND Isr Bedroom sr $50.00 E............................. 'e...i�D rA..)CONTRACTOR ....... ... � , �• ._.........-- _ ............. ....Bedroom tr $10.00 S........ .......... ADDRESS / p . ................... Dwelling Units rimes 5.............................=S................_...._..... .......................r.E Z-6... ..... f7. Phone .......................................... . Tocol3,.............................. City Business License No. .......---..................................................................... Deduct Pion Check Deposit Architect Receipt No...... .................... r;---------------------.-._.. Engineer Designer ...................................................................................................... TOTAL DUE& PAYABLE 5 ,v�` Address ............................................................._...................................... ....................................................»...-_.. .... Phone ..................................... Occupancy Group-. Division................ Type of Const......................._.......... .......................................................................................................................... FireZone............................. Use Zone........................................................... !lereby certify that I am licensed under the provisions of Chapter 9 Division 3 Site Plan &Arch.Approval No........................................................................ of the BssV and Pr es�sions C�de�of the State of California-nth*C�lo/ssUifxa- icenseFront................ Rear...._...._....... Left........... Right tion of Required No. Parking spaces........................ Striped....................................... and I further certify that 1 have in my possession, ............a certificate of can- Req. Lot area/Unit........................ Req, lot frontage....................................... sent to self-insure issued by the Director of Industrial Relations,or.............'a certificate of workman's compensation insurance issued by an admitted insurer; Special requirements ......•'•••-•'-•--•'•••.............•-'•••-••---••-•••............-••••-••---- .••••. and that the aforesaid is in ful=ndeffecl. A�w .............................._.........._..................................._...._........._._...._..._ Contractor........_... .. ........................................_...........__.................._...-----..............._ 7 -... t _ d. I hereby certify that 1 am exempt from the Contractors License Laws of the State of California under Sec. 7031.5 of the Business and Professions Code INSPECTION RECORD because of one or more of the following reasons, _TYPE DATE APP ............1 am the sole owner [Sec.70441 Foundation ............I am on employee with wages as my sole compensation (Sec.70441 --• ----- 1 am contracting with licensed contractors Concreti Slab .....I.....Aggregate total of job is less than 5100 Framing - Dore ............................... ....... Signed ......................................................... Shoot Walls Roof Sheathing 1 hereby certify that in the performance of the work for which this permit is issued, I will not employ any person in any manner so as to become subject to Lath Exterior Workman's Compensation Laws of Colifornio. Sheetrock Date............ ................ .. Signed........................................._................ Bond Beam 4 ft. 8 ft. 12 ft. 16 ft. I hereby acknowledge that I have read this application and state that the Fire Wall above is correct and I agree to comply with all City of Tracy Ordinances and - State lows regulating building. I r, to-wve, indemnify and keep harrpless the City of Tracy against h2iit" s ju menu, costs on I expenses which may FINAL BUILDING acvue against the City in cons ppnc�� n(gra tin this ermit. -----•--•- ` — - Signature of Applicant ..-�yf;r,�...... ...........� J.•--. 7 FINANCE DEPARTMENT VALIDATION Onto .....0.�. ........1.. .. Issued ........_......---••--- ---te-ev ...............-�... DOTC. pf_•.-� 7 ... PERMIT NO...�0�1G., ..................... l 11�23�'y .1,� {2 115" �'�•4yC� X21