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i DocuSign Envelope ID: B3F7B888-754D-4763-8E49-4B3295A5BA89 INTY FIRE AU'T'HORITY COMMUNITY RISK REDUCTION DIVISION CONSTRUCTION PERMIT 835 N. Central Avenue, Tracy, CA 9537E vTtf cur�F Phone (209) 831 -6707 PART I Inspection Request Line (209) 831 - 6736 �JRB f PROJECT IDENTIFICATION *LICENSED CONTRACI.OR DECLWATION- APPLICATION/PERMIT NUMBER F22-0099 I hereby off irnt under the penalty of perjury that i tint licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and license is in full force and effect. STREET ADDRESS : 3250 W GRANT LiNE RD License ft: 804431 License Class:A B HAz Expiration Date: 8131/202,3 3/22 /2022 APN: 23860006 Commom- Name �giltt� (�((ii,q Date: DESCRIPTION OF WORK: 01i'NER-BUILDER DECLARATION- Costco : Temporary Veeder-Rook Monitories Panel i) y i; (Sec 31 .5 Busiacss and Professions Code) Any city which requires n Pcnnit to construct, niter, improve, demo,0- , or PROPOSED USE OR OCCUPANCY: repair an trcbue prior to iw issuance, also requires lite applicant for such permit to file a signed statenment at hor site is license ursuruu to tic prnvisiou of the Contractors Stine License Law (Chapter 9 (commencin • m Section 700( ) of Divisim of ilia Business and Professions Code), or that he or she is exempt there from a me basis for the VALUATION OF PROJECT: $0.00 alleged exemption. A violation of Section 7031 .5 by :my applicant fora perumit subjects ilia scant to a civil penalty of not more than hundred dollars (S500). I hereby affimt undcr the fIcnallylatrpel1jury that lain exempt OWNER: from Ute Contractors License w for the reasons) indicated below by the checkmar s) 1 have placed next to the applicable itema(s). COSTCO WHOLESALE CORP, _1, as owner of ilia property, or my employees ' It wages tis ilici a compensation, will do O til( of or PHONE: 4253138100 FAX: O portions of the work, and tine structure is not inic d or It ed for sale (Sec.. 7044, Business and Professions Codc. Tire Contractors License Law dues not apply to ner of property who builds or improves thereon, and who CONTRACTOR : does such work himself or herself or through Isis or h • °rap * as, provided that such improvements are not intended or offered for sales. if, however, the building tv rovenlent is within one year of completion, the owner-builder JONES/COVEY GROUP INC will have the burden of proving that he orsl d it I build or intprm or the purpose of sale.) [, as owner of Ilse property, am usivcly contracting With licemmxcd contra rs to construct Ilia project (Sce.70441. j PHONE: 8889727581 FAX: 9094840300 Business and Professions C he Contractors License Law does not apply to at weer of tine property who builds or improves thereon, and o contracts for such projects with a contracio(s) licensed oral to the Contractor's STATE LICENSE NUMBER : 804431 License Law.) CITY BUSINESS LICENSE NUMBER : 06008098 i ilia ex t under See. Business and Professions Code for this reason ENGINEER OR ARCHITECT: ner Date IYQRKERS' COMPENSATION DECLIRATION - BARGHAUSEN CONSULTING ENGINEER 1 hereby afGnn under penalty one of Ilia following declarations. PHONE• 2069626611 FAX A252518782 Xi have and will maintain workees compensation insurance, its required by Section 3700 of the Labor Code, for the pctfomiance of the work for which this pennit is issued. My workers compensation insurance carrier and policy number are: (This section need not be completed if the permit is for one hundred dollars (SI00) or less) APPLICANT: Canicr. STARSTONE NATiONAL TNS CO Policy Number. T1021 1051 Expiration Date 5/[12022 STEVE NELSON _J certify that in the performance of the work for which this permit is issued, i shall not employ tory person in any mminer so as to become subject to the workers' compensation Imus of California, and agree that if [ .should become PHONE •4252516222 FAX subject to lite worker's compensation provisions of Section 3700 of ilia Labor Code, i shall forthwi0t comply with those provisions. I CERTIFY THAT I HAVE READ THIS APPLICATION Appliciuit 3 /22 /2022 (-f�frl�. (tus Dntr AND STATE THAT THE SHOWN INFORMATION IS CORRECT AND THAT I AM THE OWNER` OR WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGEiS UNLAWFUL, AND SHALL SUBJECT AN E4tPLOYER TO CRIMINAL PENALTIES AND CIVIL FiNES UP TO ONE DULY AUTHORIZED AGENT" OF THE OWNER , I HUNDRED THOUSAND DOLLARS ($ 100,000), IN ADDITION TO THE COST OF COMPENSATION AGREE TO COMPLY WITH ALL CITY AND STATE DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S LAWS RELATING TO BUILDING CONSTRUCTION. ; FEB, HEREBY AUTHORIZE REPRESENTATIVES OF THE -CONSTRUCTION LENDING AGENCY- CITY OF TRACY TO ENTER THE ABOVE MENTIONED PROPERTY FOR INSPECTION Applicant affirms under the penalty or perjury that there is a construction lending agency for Use perromsance of orate verification f01T11, tine work for which the permit is issued (Section 3097, Civ. C) Lender's PURPOSES . °Re altos separate Nana ._-- * *requires separate authorization form . SIGNATURE( Applicant affirms under the penalty of perjury that there is no construction leading agency for ilia performance of x(14 Uliit c__� _ X the work for which the pemtit is issued (Scetinn 3097, Civ. C) PRINT NAME Ellen Collins 4,IIPORTANT- 3 / 22 / 2022 Application is hereby made to the South San Joaquin County Fire Authority's Community Risk Reduction Division for DATE a hermit subject to ilia condition and restrictions set forth on this application, and all applicable city and state laws :rad ordinances, OWNER* X CONTRACTOR LEach person upon whose behalf this application is made and each Pelson al whose request and for whose bcncfa work is performed under or pursuant to any permit issued as a result of this application agrees to, and employees iu AGENT FOR AGENTFOR accordance with all applicable city and state laws and ordinances. 2. Any Plan Review becomes null and void after ONE HUNDRED EIGHTY ( 180) days front the date of this OWNER" CONTRACTORapplication. RECEIVED BY : DATE: NOTE: A VALID PERMIT RESULTS WHENPART 11 iS ISSUED BY THE SOUTH SAN JOAQUiN COUNTY FIRE AUTHORITY COMMUNITY RISK REDUC'T'ION DIVISION,