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CITY OF STOCKTON C)
<br /> IN EC Eff DEELOPMENT DEPARTMENT—
<br /> BUILDING DIVISION, CITY HALL PHONE:(209)937-8561
<br /> SEP 2 9 ZOOO STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request
<br /> ENVIRONMENT HEALTH PERMIT 937-8560
<br /> PERMIT/SERVICES
<br /> LICENSED CONTRACTORS DECLARATION Application Number
<br /> I hereby affirm that I am licensed under provisions of Chapter 9(commencing DO 00005765
<br /> with Section 7000)of Division 3 of the Business and Professions Code,and my license
<br /> is in full force and effect, i
<br /> CONTRACTOR
<br /> dr ss
<br /> LICENSE NO. ISSIfe ��g
<br /> LICENSE TYPE DATE C-02-.S- ANTEROS.AV 9/26/00
<br /> STOCKTONBUS,LIC,NO, Permit TYpe ; OUTSIDE CONNECTION----------21
<br /> OWNER-BUILDER DECLARATION Subdivision ;
<br /> I hereby affirm that I am exempt from the Contractor's License Law for the Parcel Nbr- ; ; 157 242 01
<br /> following reason(Sec.7031.5 Business and Professions Code:Any city or county which
<br /> requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Geo Code ; 2 7 0 I 02 11 15 4
<br /> its issuance,also requires the applicant for such permit to file a signed statement that
<br /> he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Owner NameEIGENBERGER ADAM
<br /> commencing with Section 7000)of Division 3 of the Business and Professions Code)or ,
<br /> that he is exempt therefrom and the basis for the alleged exemption.Any violation of Address 5651 N PERSHING AVE STE A-4
<br /> Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of S TOC If TON
<br /> not more[ban five hundred dollars($500.); CA 95267
<br /> ❑ I,as owner of the property,or my employees with wages as their sole Appl Type , OUTSIDE CONNECT - SEWER
<br /> compensation,will do the work,and the structure is not intended or altered for sale Oese Of Work RESIDENTIAL
<br /> (Sec.7044).Business and Professions Code:The Contractor's License Law does not
<br /> apply to an owner of property who builds or improves thereon,and who does such work SEWER LINE
<br /> himself or through his own employees, provided that such improvements are not
<br /> intended or offered for sale.If,however,the building or improvement is sold within one valuation
<br /> year of completion,the owner-builder will have the burden of proving that he did not
<br /> build or improve for the purpose of sale.) Square ftg 0 Zoning , , , ; 060
<br /> ❑ I, as Owner of the property, am exclusively contraafing with licensed Occup Group , , Const Type ;
<br /> contractors to construct the project(Sec.7044,Business and Professions Code:The
<br /> Contractor's License Law does nota to any owner of properly who builds or
<br /> improves thereon,and who c s for s projects with a contractor(s)licensed
<br /> pursuani tothe Comra"or'sL nsoLaw.) S ectal Notes and-Conditions
<br /> ❑Aammpt nder See., Ba P.C.for this PROJ: THIS IS A PERMIT FR CONNECTION FEE
<br /> reasoPROD; COLLECTION ONLY. A BUILDING PERMIT
<br /> Daleowner ROJ; MUST BE OBTAINED FROM THE COUNTY
<br /> RETUICY: I AM ARE IF MY CHECK IS RETURNED TO THE PROD; OF SAN JOAQUIN PRIOR TO THE
<br /> CITY, REVOKEDAM ALSO WARE,1F ANY WORT(HAS BEEN PROD; COMMENCEMENT OF WORT(r
<br /> STARWILL IMP SE AN ESTIGATION FEE, (PER SMC 13"304(CREQUI DF
<br /> NOTE:To protest the Imposition of any development fee,dedication,reservation __ __
<br /> or other exaction imposed on your project,you must file written notice with the - -
<br /> City Clerk's Office within 90 days after approval of the project or imposition of the PERMIT TOTAL .00
<br /> fees, dedications, reservations or other exactions stating that the required
<br /> payment is tendered or will be tendered when due,or that any conditions which
<br /> have been Imposed are provided for or satisfied, under protest, along with a
<br /> statement of the actual elements of the dispute and the legal theory forming the
<br /> basis for the protest.
<br /> WORKER'S COMPENSATION DECLARATION
<br /> i hereby affirm that I have a certificate of consent to self-insure,or a certificate
<br /> of Workers'Compensation Insurance,or a certified copy thereof(Sec.3600,Lab,C.)
<br /> Policy NO.
<br /> Company
<br /> ❑ Certified copy is hereby furnished.Expires
<br /> ❑ Certified copy is filed with the city building inspection department.
<br /> Date ,Applicant
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
<br /> This section need not be completed it the permit is for one hundred dollars
<br /> ($100)Or less.
<br /> I certify that in the performance of the work for which this permit is issued.I shall -
<br /> not employany person in any manner so as to become subject to the Workers' �
<br /> Compensation Laws of California.
<br /> Elate Applicant
<br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should
<br /> become subject to the Workers'Campensalion provisions of the Labor Code,you must
<br /> forthwith comply with such provisions or this permit shall be deemed revoked.
<br /> I certif hat I have read s application and state that the above information is
<br /> correct.I ee t empty with Irrccill and county ordinances and stab laws relating to
<br /> building tructio and hereb}, uthorize representatives of this city to enter upon the
<br /> above a to e i n ur
<br /> SIGN
<br /> JOB RESS ADDRESS
<br /> APPLICATION AP OVAL
<br /> THIS PERMIT DOES NOT BECOME VALID NED BY THE BUILDING
<br /> OFFICIAL OR HIS DEPUTY AND FEES RE ID.
<br /> SIGNATURE:
<br />
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