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CITY OF STOCKTON <br /> CF (''­ [UNITY DEVELOPMENT DEPARTMENT <br /> BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 <br /> STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request <br /> PERMIT560 <br /> 937-8r <br /> Application Nuaber <br /> O4 00006550 <br /> hif <br /> Jab Address IssOe bale <br /> 870 GRIDER WY 4/10/04 <br /> Permit Type : GENERAL PLUXOING PERATT-----2L <br /> - - _ Subdivision . <br /> Parcel Or : 010 160 29 <br /> the Geo :ode 3208 O1 02 14 <br /> use OWoer flame STOCKTON CITY Of <br /> med! <br /> Ines, Address . . . : 22 E WEBER AYE SUITE 350 <br /> and <br /> aged STOCKTON CA 95202 <br /> ;the <br /> kppi Type ELECTRICAL, PLUXBTNG, XECNANICAL-NON RES <br /> g. sole Gest of Work : RESIDENTIAL <br /> ces WATER METER <br /> leas Valaatioi,once <br /> L J. 0 <br /> that square f i9 . . 0 fiA <br /> Occup Group Const Type . <br /> hied <br /> III orspecial Notes and Conditions <br /> PROJ: WATER METER 1a DOXESTH <br /> s <br /> ,aaso„ - - - - - - - - - - - - - - FEES - - - - - - - - - - - - - - - <br /> �p — /JT erDy IF-ADNIN FEE (3.55) {[1 36.33 <br /> r-il— ---------- <br /> N-WATER-11DONESTIC 11 1,038,00 <br /> NOTE: To protest the imposition of any development fee, dedication, FERNTT TOTAL 1,Q76,33 <br /> reservation or other exaction Imposed on your protect,you must file written <br /> notice with the City Clerk's attire within W days after approval of the project <br /> or imposition of the fees,detlications,reservations or other exaclions sating <br /> that the required payment is tendered or will ne tendered when due,or that <br /> any conditions which have been imposed are provided for or satisfied,under <br /> protest,along with a statement of Me actual elements of the dispute and the <br /> legal theory forming the basis for the protest. <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm that I have a camisole of consent to self-insure,or a cer ipcate <br /> of Workers Compensation Insurance,or a cedified copy thereof(Sec.3800,Lab.C) <br /> Policy No. <br /> Company <br /> ❑ Certified copy is hereby funished.Expires <br /> ❑ Certified copy is filed with the city building Inspection department o <br /> Data .Applicant <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCEor less. <br /> This section need rot be completed H the permit is for one hundred dollars <br /> Ice, that in Hte pedon,ance of the wodc for which this peril or issues,I <br /> shall rot empty awry person In any manner so as to become subject to the Workers' <br /> shall <br /> .e tion Laws of CaMomia. ,f •'J <br /> Date Applicant A� <br /> NOTICE TO APPLICANT:H.after making this Certificate of Exemption you should bn <br /> become subject to the Workers Compensation provisions of the tabor Code,you <br /> must forthwith comply with such provisions or this permit shall be deemed reveled <br /> 1 candy that I have read this application and Sale that the above information <br /> Z <br /> correct agree to centdV+iHh��tydry ordinarcesrelating to building o yI cHOn,arieseMeliBhtar itHla 8b 'ems' lian IPQSee. <br /> SIGNED <br /> ADDf'ESS ���NNNVVV/// <br /> OR R SS <br /> APPLICATION APPROVAL \ <br /> THIS PERMIT DOES NOT BECOME VALID UNTIL SIGNED BY THE BUILDING <br /> OFFICIAL OR HIS DEPUTY AND FEES ARE PAID�IA.v� <br /> SIGNATURE—� {� <br />