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( � CITY OF STOCKTON fewa �I�� Jr��MMUNITY DEVELOPMENT DEPARTMENT �C 1J L� BUILDING DIVISION, CITY HALL PHONE: (269)937-8561 A9# STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request SSP 2 2000 937-8560 ENVIRONMENT 1rHEALTH PERMIT LICENSED CONTRAROMI[TCk#tAtlb ICES Application Number I hereby affirm that I am licensed under provisions of Chapter 9(commencing 00 00005784 with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. CONTRACTOR Job Address _ LICENSE NO. LICENSE TYPE DATE X366 S ANTEROS AV 9/28/00 � STOCKTON BUS. IC.NO. Permit Type ; OUTSIDE CONNECTION----------2L OWNER-SUELDERDECLARATION Subdivision I hereby affirm that I am exempt from the Contractor's License Law for the 1Pareel+Nbr'- , ;- 157 -230 20 - > following reason(Sec.7031.5 Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Geo Code its issuance,also requires the applicant for such permit to file a signed statement that hs is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Owner Name EIGENBERGER ADAK commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Address . . . ; 5651 N PERSHING AVE STE A4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500.): STOCKTON CA 95202 ❑ I,as owner of the property,or my employees with wages as their sole Appl Type ; OUTSIDE CONNECT - SEWER compensation,will do the work,and the structure is not intended or offered for sale D2SC Of Work RESIDENTIAL (Sec.7044).Business and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work SEWER LINE himself or through his own employees, provided that such improvements are not intended or offered for sale.II,however,the}wilding or improvement is sold within one Valuation year of comptelion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) Square ftg ; 0 Zoning . NA ❑ I, as owner of the property, am exclusively contracting with licensed OCCUp Group ' Const Type , contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not apps to an owner of property who builds or improves thereon,and who contracts 'acts with a contractors)licensed pursuant to the Contractor's Licens .} Special Notes and Conditions ❑ lam exemptund ec. Pe.for,hi� PROJ; THIS IS A PERMIT FOR CONNECTION reason PROJI FEE COLLECTION ONLY, A BUIDING Date owner f AIAT MUST BE OBTAINED FROM THE RETURN CHECK POLIO : I AM AR IF MY HECK IS RETURNED TO THE PROJ; COUNTY OF SAN JOAQUIN PRIOR TO CITY,THIS PE ISARE.IF ANY WORK HAS STARTED, THEMCITY RILL. I POSEM NL IN STIGATION FEE, (i SMCEEN 13- PROD; THE COMMENCEMENT OF WORK. 304(C))PLUS ANY OTHE REQUIRED FEES NOTE:To protest the tmpo '' n of development fee,dedication,reservation or other exaction imposed on your project,you must file written notice with the ---"----"" s City Clerk's office within 90 days alter approval of the project or Imposition of the PERMIT TOTAL j fees, dedications, reservations or other exactions stating that the required .00 h payment Is tendered or will be tendered when due,or that any conditions which have been imposed are provided for or satisfied, under protest,along with a statement of the actual elements of the dispute and the legal theory forming the basis for the protest. WORKER'S COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell-insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company ❑ Certified copy is hereby furnished.Expires ❑ Certified copy is lidd.with the citybuilding inspection department. Data ,Applicant CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be completed if the permit is for one hundred dollars ($109)or less. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to became subject 10 the Workers' j Compensation Laws of California. Dale Applicant NOTICE TO APPLICANT: If, alter making this Certificate of Exemption you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. 1 certify that Ia e read this application and state that the above information is correct.1 e[o co p with all city and county ordinances and slate laws relating to uiidi const clian I bthorize re resentalives of this city to enter upon the abo I, SI D J08 DDRESS ADDRESS APP ON APPROVAL ' THIS PE DOES NOT B M LID UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS DEPUT E A E PAID. t i SIGNATURE: