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<br /> ° q,.•. '' Ran Joaquin County
<br /> ri p p
<br /> Communi Development Department
<br /> "t 1810 E.Hazelton Ave,Stockton,Ca 95205 Permit Number:
<br /> •:.:,,� c• Business Phone(209)468-3121 BP-1702587
<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 am licensed under provisions ofChapter9(commencingwith Section 7000)of permit Address: 11851 W VALPICO RD
<br /> Division 3 of the Business and Professions Code,and my license is in full force and effect.
<br /> License# Exp.Date Cross Street: CORRAL HOLLOW
<br /> Date Contractor City: TRAC
<br /> OWNER-BUILDER DECLARATION Owners Name: PENH,AURORA
<br /> I hereby affirm that I am exempt from the Contractors License Law for the following reason. Phone:
<br /> (See.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 Contractors Applicant Name: PENH,AURORA
<br /> License Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and
<br /> Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any Address: 11851 W VALPICO RD
<br /> violati of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of City: TRACY CA 95376-9124
<br /> n ors than five hundred dollars(5500.00).):
<br /> I,as owner of this property,or my employees with wages as their sole compensation,will do Phone:
<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:
<br /> who builds or improves thereon,and who does such work himself or through his own
<br /> employees,provided that such improvements are not intended or offered for sale. If, Address:
<br /> however,the building or immprovement is sold within one year of completion,the City:
<br /> owner-builder wil I have the burden of proving that he did not build or improve for the
<br /> sc mf sale,) State License: Exp:
<br /> 71,as owner of the property,am exclusively contracting with licensed contractors to construct Phone:
<br /> the project.(Sec.7044,Business and Professions Code: The Contractors 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 contractor/contractor(s)license pursuant to the Contractors License Designer Name:
<br /> Law.) Address:
<br /> F7 I ant exempt under Sec. of the ness and Professions Code for the
<br /> following reason: City:
<br /> Date owner Q71 License#:
<br /> Phone#:
<br /> WORKERS'COMP ATION DECLARATION
<br /> 1 hereby affirm under penalty of perjury one of to following declarations:
<br /> F71 1 have and will maintain a certificate of sent to self-insure for workers'compensation, Scope of Work: CONVERT UNPERMITTED
<br /> as provided for by section 3700 of the or Code,for the performance of the work for HABITABLE SPACE BACK TO SHOP/STORAGE AT
<br /> which this permit is issued. SFR(SEE EN-1700205)
<br /> 1 have and will maintain workers' Pe tion insurance,as required by section 3700 0(
<br /> the Labor Code,for the performan of the work for which this permit is issued. My
<br /> workers'compensation insurance 'er and policy number are on file with the State Item Description pti on Tot Fee
<br /> Con tors License Board. ----- ------------------------------ ---------
<br /> 1 certify that in the performanc of the work for which this permit is issued,I shall not 1000 BU i l di ng Fee 100.00
<br /> employ any person in any man er so as to besubject to the workers'compensation laws 1010 Imaging/Teehnol ogy 15.00
<br /> of California,and agree that if 1r
<br /> com so ect to the workers'compensation 5030 General Pl an Imp ement 5.00
<br /> provisions of Section 3700 of thee s I orthwith corn wit t eprovision. ��Date Please see reverse side for important information.
<br /> WARNING: AILURE TO SECRS COMPENSATION COVERAGE ISUNLAWFUL AND SHALL SUBEMP YER TO CRIMINAL PENALTIES AND
<br /> CIVIL FINES UPTOONE HUNU D DOLLARS(S 100,000),IN ADDITION
<br /> TO THE COST OF COMPENSAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTERATTORNEY5 FEES.CONION LENDING AGENCYI hereby affirm that there is a consnding agency for the performance of the work for which
<br /> this permit is issued(Sec.3097,C .
<br /> Lenders Name Address
<br /> City/State Phone
<br /> DIVISION OF INDUSIRIAL SAFETY PERMIT CERTIFICATION
<br /> hereby certify that no excavation five(5)or more feet in depth into which a person is
<br /> required to descend,will be made in connection with work authorized by this permit,and that
<br /> no bu' ing,structure,scaffolding falsework,or demolition or dismantling thereof,will be
<br /> Twnpifian thirty-six (36)feet high.(Chap.3.2,Grp.2,Art,2,Sec,341,Titleg,C.A.C.)
<br /> As 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
<br /> work from the Division.
<br /> ODivision of Industrial Safety Permit No.
<br /> I certify that I have read and state that the4infbtioniven is correct. I agree to comply with all
<br /> some laws and county ordinances relating nslmction,and authorize representatives of
<br /> the Issuing Jurisdiction to enter upon theed property r t ction purposes.
<br /> Signature f Legal Owner or Auth
<br /> Date!�f'(, Applicant
<br /> Accepted:IAA Approved:JA A plied Date:07/14/2017 Issue Date:07/14/2017 APN:242-050-04 Valuation:$0.00 SgFt:0
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