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<br /> tall Joaquin County
<br /> Community Development ll�epartment
<br /> Permit Number:
<br /> E.Hazelton Ave,Stockton,Ca 95205
<br /> •' y t , 1810• Business Phone(209)468-3121 BP-1603838
<br /> Request For Inspection Phone(209)468-3165(24 Hour Recorder)
<br /> or on the web at sjgov.org
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I hereby affirm that I mn licensed under provisions of Chapin 9(commencing with Section 7000)of Permit Address: 31411 S KASSON RD
<br /> Division 3 of the B e P��Ys�i Code,and my license is rn f I e trod a bcr.
<br /> License p `x-f Exp.Date Cross Street: DURHAM FERRY
<br /> Date 11A d Z, Contractor City: TRAC
<br /> OWNER- UI ER DECLARATION Owners Name: PETLANSKY,JOHN M TR ETAL
<br /> I hereby affirm that I am exempt from Contractors License Law for the following wason. Phone:
<br /> (Sec.7031.5,Business and Profession Cutke'Any city m county which requires a permit to construct,
<br /> alter,improve,demolish,or repair structure,prior to its issuance,also requires the applicant for
<br /> such permit to file a sigrmed std that he is licensed pursuant to the provisions ofdmc Contractor's Applicant Name: ROOTER PRO PLUMBING INC DBA
<br /> License Law(Chapter 9commenci with Section 7000)of Division 3 of the Busities&and KNIGHTS PLUMBING AND DRAIN
<br /> Professions Code)or that he is ex i therefrom and the basis for the alleged exemption. Any
<br /> violation of Section 7031.5 by any applicant fur u permit subjects the applicant to a civil penalty of Address: 1177 V ANDERBILTCIRCLE STE#5
<br /> not more than five hundred dollars($500.00).):
<br /> aI,as owner of this property,or my cmployces with wages as their sole compensation,will do City: M ANTECA CA 95337
<br /> the work,and the structure is not intended or offered for sale.(Sec.7044.Business aid Phone: 209 823-5243
<br /> Professions Code: The Contractor's License Law does not apply to an owner or property
<br /> who builds or improves thereon•and who does such work himself or through his own
<br /> employees,provided that such improvements an not intended or otlered for sale. If, Contractor Name: ROOTER PRO PLUMBING INC DBA
<br /> however,the building orimmpmvenxntissold within one year of completion,the KNIGHTS PLUMBING AND DRAIN
<br /> owner-builder will have the burden of proving that he did not build or improve for ii
<br /> se of salt.) Address: 1177 VANDER Bi LTCIRCLE STE#5
<br /> fI,as owner of the property, exclusivelyoontractingwith licensed contractors to rnnstruct City: MANTECA CA 95337
<br /> the project(Sec.7044,Business and Professions Code: The Contractor's License Law does State License: 813548 Exp: 10/31/2016
<br /> not apply to an owner of property Alio builds or improves thereon,and who contracts for
<br /> such projects with a contractoVeontmcnor(s)license pursuant so(he Contractor's License Phone: 209 823-5243
<br /> Law)
<br /> EDam exempt under Sec. ,of the Business and Professions Code for the
<br /> followingreason: Designer Name:
<br /> Date owner Address:
<br /> City:
<br /> WORKERS'COMPENSATION DECI,AR.4TiUN
<br /> 1 hereby-affirm under penalty of perjuryone of the following declarations- License#:
<br /> r7t have and will maintain a certificate of consent to self-insure for workers'compensation, Phone#:
<br /> as provided for by section 3700 of the Labor Code,for the pcdommance of the work for
<br /> which aveandwill nit nitu Scope of Work: REPLACE EXISTING WATER
<br /> J have and will maintain workers'compouation insunmce,as required by section 37DO of p
<br /> the Labor Code,for the performance of the work for which this permit is issued. My HEATER W/NEW TANKLESS WATER HEATER
<br /> workers'compensation insurance carrier and policy number ore on file with the State AT SFR
<br /> Contractors License Board.
<br /> Q1 certify that in the petfomance of the work for which this pamrit is issued,l shall mror
<br /> employ any person in any manner so as to become subject to the workers'compensation laws Item Description Tot Fee
<br /> of Cali forriia.and alpre that if I should become subject to the workers'Compensation ----- ------------------------------ ---------
<br /> provisions of Section 3700 of the Labor Cale sh forthwith connply with these 1010 Imaging/Technology 15.00
<br /> pro 1017 Plumbing Fee 100.00
<br /> Date Applicant 5030 General Plan Implement 5.00
<br /> WARNING:FAILURE TO SECURE W RS'COMPENSATION COVERAGE IS
<br /> UNLAWFUL AND SHALL SUBJECT A MPLOYER TO CRIMNAL PF.NAL'I'IES AND
<br /> CIVTLFiNL'SUPTOONEHUNDRL'D HO SAND DOLLARS($100,000),iNADDITION Please See reverse Side for important information.
<br /> TO THE COST OF COMPENSATION AMAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTEREST, ND A7-1.ORNEY'S FEES.
<br /> CONSTR CTION LENDING AGENCY
<br /> I hereby affirm that there is a construct n lending agency for the performance of the work for which
<br /> this permit is issued(Sec 3097,Civil Code).
<br /> Lendcfs Name Address
<br /> Citylstate Phone
<br /> DIVISION OF INDUSTRIALSAFFIY PERAiITCER77FiCAIION
<br /> I hereby certify that no excavation five(5)or more feet in depth into which n person is
<br /> required to descend,will be made in connection with work authorized by this permit,and that
<br /> no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be
<br /> rum than thirty-six (36)feet high.(Chap.3.2,Grp.2,Art.2,Sec.341,Titles,C.A.C.)
<br /> ❑As ow•ner•builder.I will trot employ anyone to do work which would require a pcnnil from
<br /> the Division of industrial Safety,as noted above,unless such person has a permit to do such
<br /> work from the Division.
<br /> ODivision of industrial Safety Permit No.
<br /> I certify that)have read and state that the infommtion given is correct. I agree to comply with all
<br /> state laws and county ordinances relating to building construction,and authorize representatives of
<br /> the issuing Jurisdiction to enter upon the abo - esLribed property for inspection purposes.
<br /> Signature or LegYl Owner or Auth rRx Agent
<br /> DYte _Applicaat
<br /> Accepted:JAA Approved:J AWMicd Date:10/03/2016 Issue Date: 10/03/2016 APN:255-340-01 Valuation:$0.00 Sq Ft:0
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