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S A N �J O A Q U I N Community Development Department
<br /> 1810 E . Hazelton Ave Stockton, Ca 95205 Permit Number .
<br /> COUNTY Business Phone (209) 468 -3121
<br /> ...'�_. � Request For Inspection Phone (209 ) 468 -3165 (24 Hour Recorder) BP -2301488
<br /> �crFOR� Greatness grows here. or on the web at www. sjgov . org/commdev
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000 ) of Permit Address ' 81255 S EL DORADO ST
<br /> Division 3 of the Business and Professions Code, and my license is in full force and effect.
<br /> License # Exp . Date Cross Street : MATHEWS RD
<br /> Date Contractor City : FREN
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason. Owners Name : VALDEZ EUGENIA D
<br /> (Sec . 7031 . 5 , Business and Professions Code : Any city or county which requires a permit to construct, Phone :
<br /> alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such
<br /> permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License
<br /> Law (Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code) or Applicant Name : MATT THOMAS
<br /> that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 . 5 by Address : 5444 DRY CREEK RD
<br /> any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars City : SACRAMENTO , CA 95838
<br /> $( 500 .00) . :
<br /> aI, as owner of this property, or my employees with wages as their sole compensation, will do the Phone : ( 916 ) 9914100
<br /> work, and the structure is not intended or offered for sale . (Sec . 7044 , Business and Professions
<br /> Code : The Contractor's License Law does not apply to an owner or property who builds or Contractor Name : C G R S INC
<br /> improves thereon, and who does such work himself or through his own employees , provided that
<br /> such improvements are not intended or offered for sale . If, however, the building or improvement Address : 5444 DRY CREEK ROAD
<br /> is sold within one year of completion, the owner-builder will have the burden of proving that he City : SACRAMENTO CA 95838
<br /> did not build or improve for the purpose of sale . )
<br /> I, as owner of this property, or my employees with wages as their sole compensation, will do the State License : 803616 Exp : 01 /31 /2024
<br /> work, and the structure is not intended or offered for sale . ( Sec . 7044, Business and Professions Phone : 6266278316
<br /> Code : The Contractor's License Law does not apply to an owner or property who builds or
<br /> improves thereon, and who does such work himself or through his own employees, provided that
<br /> such improvements are not intended or offered for sale . If, however, the building or improvement Designer Name :
<br /> is sold within one year of completion, the owner-builder will have the burden of proving that he Address :
<br /> did not build or improve for the purpose of sale .) City :
<br /> 0 I, as owner of the property, am exclusively contracting with licensed contractors to construct the
<br /> project. (Sec. 7044, Business and Professions Code : The Contractor' s License Law does not License # :
<br /> apply to an owner of property who builds or improves thereon, and who contracts for such Phone # :
<br /> projects with a contractor/contractor(s) license pursuant to the Contractor' s License Law. )
<br /> I am exempt under Sec . of the Business and Professions Code for the following Scope of Works. EXTEND (E) MASONARY CONTAINMENT
<br /> reason :
<br /> Date Owner ENCLOSURE AROUND (E) DIESEL
<br /> WORKERS ' COMPENSATION DECLARATION TANK AT J&L MARKET
<br /> I hereby affirm under penalty of perjury one of the following declarations :
<br /> I have and will maintain a certificate of consent to self4risure for workers' compensation, as
<br /> provided for by section 3700 of the Labor Code, for the performance of the work for which this Item Description Tot Fee
<br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> permit is issued . 900 Plan Check Fee 350 . 00
<br /> 0 I have and will maintain workers' compensation insurance, as required by section 3700 of the 1000 Bui 1 di ng Fee 350 . 00
<br /> Labor Code, for the performance of the work for which this permit is issued. My workers' 1009 Plot Plan Review 64 . 00
<br /> compensation insurance carrier and policy number are on file with the State Contractors License 1010 Imaging /Technology 15a00
<br /> Board . 1011 Info Technology Recovery 26 . 91
<br /> 0 I certify that in the performance of the work for which this permit is issued, I shall not employ any 5030 General Plan Implement 17 . 50
<br /> person in any manner so as to become subject to the workers' compensation laws of California,
<br /> and agree that if I should become subject to the workers' compensation provisions of Section 3700
<br /> of the Labor Code, I shall forthwith comply with these provisions .
<br /> Date Applicant Please see reverse side for important information .
<br /> WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL
<br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
<br /> ONE HUNDRED THOUSAND DOLLARS ($ 100 ,000), IN ADDITION TO THE COST OF
<br /> COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
<br /> INTEREST, AND ATTORNEY' S FEES ,
<br /> CONSTRUCTION LENDING AGENCY
<br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this
<br /> permit is issued (Sec. 3097 , Civil Code) .
<br /> Lender's Name Address
<br /> City/State Phone
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> 0 I hereby certify that no excavation five (5) or more feet in depth into which a person is required
<br /> to descend, will be made in connection with work authorized by this permit, and that no building,
<br /> structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six
<br /> (36) feet high . (Chap . 3 .2 , Grp . 2 , Art. 2 , Sec . 341 , Title8 , C .A. C . )
<br /> As owner-builder, I will not employ anyone to do work which would require a permit from the
<br /> Division of Industrial Safety, as noted above, unless such person has a permit to do such work
<br /> from the Division .
<br /> Division of Industrial Safety Permit No .
<br /> I certify that I have read and state that the information given is correct. I agree to comply with all state
<br /> laws and county ordinances relating to building construction, and authorize representatives of the Issuing
<br /> Jurisdiction to enter upon the above-described property for inspection purposes .
<br /> Signature of Legal Owner or Authorized Agent
<br /> Date Applicant
<br /> Accepted : JAA Approved : GD Applied Date : 05/ 18/2023 Issue Date : 10/23 /2023 APN : 19347043 1 Valuation : $0 . 001 SgFt : 0
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