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.r..E .o San Joaquin County
<br /> r. y Department Community DevelopmentDe
<br /> `.� P Permit Number:
<br /> { 1810 E.Hazelton Ave,Stockton,Ca 95205
<br /> •i , Business Phone(209)468-3121 BP-0403664
<br /> _ .•P Request For Inspection Phone(209)468-3165(24 Hour Recorder)
<br /> tk ' or on the web at sjgov.org
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section 7000)of permit Address' 31411 S KASSON RD
<br /> 3 of the Business and Professions Code,and my license is in full force and effect.
<br /> License#_ Exp.Date_ _ Cross Street: DURHAM FERRY RD
<br /> DateContractor_ City: TRAC
<br /> OWNER-BUILDER DECLARATION Owners Name: PETLANSKY,JOHN M TR ETAL
<br /> 1 hereby affirm that i am exempt from the Contractor's License Law for the following reason. Phone:
<br /> (Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,
<br /> alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for
<br /> such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's Applicant Name: T C CONSTRUCTION
<br /> License Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and Address: 615 N C ST
<br /> Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any
<br /> violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of City: TRACY,CA 95376
<br /> not mon:than five hundred dollars(5500.00).):
<br /> 0 1,as owner ofthis property,or my employees with wages as their sole compensation,will do Phone: 835-2470
<br /> the work,and the structure is not intended or offered for sale.(Sec.7044,Business and
<br /> Professions Code: The Contractors License Law does not apply to an owner or property Contractor Name: T C CONSTRUCTION
<br /> who builds or improves thereon,and who does such work himself or through his own
<br /> cmplo)ees,provided that such improvements are not intended or offered for sale. If. Address: 615 N C ST
<br /> however,the building or intmprovement is sold within one year of completion,the City: TRACY,CA 95376
<br /> owner-builder will have the burden of proving that he did not build or improve for the
<br /> �l
<br /> u se of sale.) State License: 542481 Exp:07/31/2010
<br /> ,as owner ofthe property,ant exclusively contracting with licensed contractors to construct Phone: 835-2470
<br /> the project.(Sec.7044,Business and Professions Code: The Contractor's License Law does
<br /> not apply to an owner of property who builds or improves thereon,and who contracts for
<br /> such projects with a con(ractor/contmclor(s)license pursuant to the Contractor's License Designer Name:
<br /> Law.) Address:
<br /> OI:un exempt under Sec. ,of the Business and Professions Code for the
<br /> fol lowing reason: City:
<br /> License#:
<br /> Dine Owner
<br /> — — Phone#:
<br /> WORKERS'COMPENSATION DECLARATION
<br /> iherebyaffirmunder penaltyofperjury one ofthefollowing declarations: Scope ofWork: DETACHED NON CONDITIONED
<br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,
<br /> as provided for by section 3700 of the Labor Code,for the performance of the work for REC ROOM W/2 BATHS AND PORCH
<br /> which this permit is issued.
<br /> OI have and will maintain workers'compensation insurance,as required by section 3700 of
<br /> the Labor Code,for the performance of the work for which this permit is issued. My item Description Tot Fee
<br /> workets'compensation insurance carrier and policy number are on file with the State ----- ------------------------------ ---------
<br /> Contractors License Board. 900 Plan Check Fee 372.48
<br /> Q 1 certify that in the performance of the work for which this permit is issued,I shall not 1000 License & Permits 573.05 I
<br /> employ any person in any manner so as to become subject to the workers'compensation laws 1004 State Smi p Fee 95% 4.06
<br /> of California,and agree that if I should become subject to the workers'compensation Smi p Fee - CDD S% .21
<br /> provisions of Seclion 3700 of the Labor Code,I shall forthwith comply with these 10010059 Plot Plan Review 30.00
<br /> 1010 imaging/Technology 34.38
<br /> provisions. 1017 Plumbing Fee 50.00
<br /> DateApplicant 1018 mechanical Fee 50.00
<br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS 1019 Electrical Fee 60.00
<br /> UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND 5029 Pw-Bui 1 di ng/Grading Fees 30.00
<br /> CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),iN ADDITION 5030 General Plan implement 36.65
<br /> TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
<br /> CONSTRUCTION LENDING AGENCY Please see reverse side for important information.
<br /> I hereby affirm that there is a construction lending agency for the performance of nhe work for which
<br /> this permit is issued(Sec.3097,Civil Code).
<br /> Lender's Name Address
<br /> City/Sute Phone
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> 1 hereby certify that no excavation five(5)or more feet in depth into which a person is -
<br /> retluired to descend,will bemade in connection with work authorized by this permit,and that 4 /
<br /> no building,structure,scaffolding,falsewok,or demolition or dismantling thereof,will be (_ E (k_
<br /> more than thirty-six (36)feet high.(Chap.3.2,Grp.2,Art,2,Sec.341,Titles,C.A.C.)
<br /> 0 A.a owner-builder,I will not employ anyone to do work which would require a permit from
<br /> the Division of industrial Safety,as noted above,unless such person has a permit to do such �' 1(� f �;L r, L 1( i ) ) t- f v
<br /> work from the Division. `
<br /> 0 Division of industrial Safety Permit No.
<br /> 1 certify that I have read and state that the information given is correct. 1 agree to comply with all ��l6'. .(i _ rl.L ti ALL• '�: `� 0 yl L
<br /> state laws and county ordinances relating to building construction,and authorize representatives of
<br /> the issuing Jurisdiction m enter upon the above-described property for inspection purposes.
<br /> Signature of Legal Owner or Authorized Agent C )
<br /> Date Applicant -�Cx E'C Imo_: ! 4�L kzkL t)�, 1.L.t/ v i�: ` > Ll
<br /> Accepted:RC Approved:DRO Applied Date:08/13/2004 Issue Date:09/10/2004 APN:255-340-01 Valuation:$42,705-60 SgFt:2016
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