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CITY OF STOCKTON `i` tiOMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request 937-8560 P ERMIT A)pllcatlon Nuaber LICENSED CONTRACTORS DECLARATION Gi UiJVGYUUS I hereby affirm that t am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. iilb AUOre�s :sblle lute CONTRACTOR - nn 2134 WATERLOO Ru 9 �7510i LICENSE NO. LICENSE TYPE DATE Perri-It Ty;;e OUTaIDr; CON NECTION-__----___4L STOCKTON BUS.LIC.NO. i OWNER-BUILDER DECLARATIONilD(�iVi5i1 I hereby affirm that I am exempt from the Contractor's License Law for the Parcel Nbr 141 i$i. I9 following reason(Sec.7031.6 Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure, Cco CUiie , prior to its issuance,also requires the applicant for such permit to file a signed �_ �I r_ -.-.czll r statement that he is licensed pursuant to the provisions of the Contractor's License Owner Kase , , Tis Yynh k]015)t A d MARIA Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and t Professions Code)or that he is exempt therefrom and the basis for the alleged rtia3r2ss . 2403 vrA1 AV exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the m n applicant to a civil penalty of not more that five hundred dollars($500.): isu,uCi l Cixzt CA 9 J 2 ti 5 I,as owner of the property,or my employees with wages as their sole Apel type OUI S Ii7S CONNECT - SHE Rr compen,will do the work,and the structure is not intended or offered for sale +;„n fs (Sec.7044}.Business and Processions Code:The Contractors License Law does 4)aluo-4ion , v not apply to an owner of property who builds or improves thereon,and who does u Gare }i U GOTiirtQ NA such work himself or through his own emptoyees,provided that such improvements ` are not intended or offered for sale.If,however,the building or improvement is sold Occu GrOI`+i1 Const Type , within one year of completion,the owner-builder will have the burden of proving that he did net build or improve for the purpose of sale.) ❑ I,as owner of the property,am exclusively contracting with licensed special Notu aliC Condiliiilis contractors to construct the project(Sec.7044,Business and Professions Code: !; ry,Tm Q Yi _; TheContractol'sLicenseLawdoesnotapplytoanyownerofpropertywhobuildsor AN ENCROACHMEN PERMIIS QUIRED PRIOR improves thereon,and who contracts for such projects with a contractors)licensed r z f n f3t- pursuant to the Contractor's License Law.) 1G CCINNECTHUN TO A CITY MAINTAINED ❑ I am exempt under Sec. ,B&P.C.for this UTILITY THIS IS A PERMIT ICOR THETHECOLIJECTIOR LP reason oat Owner zA SEWER CONNECTION FERC ONLY. A BUILDING PERMIT MUST BE CHAINED FROM THE COUNT Of SAN OOAQIUIN PRIOR TO TH COMMENCEMENT OF WORK NOTE:To protest the imposition of any development fee,dedication, uUT3IGIS SEWER CONNECTION reservation or other exaction Imposed on your project,you must file written notice with the City Clerk's office within 90 days after approval of the project or imposition of the fees,dedications,reservations or other exactions stating ------- that the required 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 PERIR 'TOTAL .C� legal theory forming the basis for the protest. WORKER'S COMPENSATION DECLARATION �y~^ I hereby affirm that 1 have a certificate of consent to self-insure,or a certificate o1 Workers'Compensation Insurance,or a Certified copy thereof(Sec.3800,Lab.C.) Policy Company 4 �+ I ❑ Certified Copy is hereby furnished.Expires ❑ Certified copy is filed with the city building inspection department. ---------• - Date ,Applicant CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be completed if the permit is for one hundred dollars ($1 DO)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 become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption you should become subject to the Workers'Compensation provisions of the tabor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. I certify that I have read this application and state that the above information is correct.1agree to comply with all city and county ordinances and state laws relating to building con struMion,and hereby authorize representatives of this city to . enter upo the abover mentioned erty for inspection purposes. l JOBN SIGA RESS �E �� ' ADDRESS APPLICATION APPROVAL THIS PERMIT DOES NOT BECOME VALID UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS DEPUTY AND FEES ARE PAID. SIGNATURE