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San Joaquin County
<br /> Community Development Department Permit Number:
<br /> 1810 E.Hazelton Ave,Stockton,Ca 95205 $p_1704834
<br /> Business Phone(209)468-3121
<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 affutn Shat I am licensed under provision of Chapter 9(commencing with Section 7000)of permit Address: 11851 W VALPICO RD
<br /> Division 3 ofthe Business and Professions Code,and my license is in full force and effect.
<br /> Liceeaa 0 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 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 rile a signed statement that he is licensed pursuant to the provisions of the Contractor's 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 /> violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of City: TRACY CA 95376-9124
<br /> not re than five hundred dollars($500.00).):
<br /> LJ'•as owner of this property,or my employees with wages as thea 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 properly 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 munprovement is sold within one year of completion,the City.
<br /> owner-builder will have the burden of proving that he did not build or improve for the
<br /> nse of sale.) State License: Exp:
<br /> I,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 /> aI am exempt under Sec. f k Business and Professions Code for the
<br /> following reason: City.
<br /> SX L, -t1 _ - License#:
<br /> Date — Phone#:
<br /> Ow"
<br /> WORKERS'CO EN TION DECLARATION
<br /> I hereby affirm under perehy of perjury o of the Ifo declarations:
<br /> I have and will maintain a eremitical f consent to self-neuro for workers'compo cation, Sf,011C Of Work: ADDITION OF BATHROOM WITHIN
<br /> as provided for by action 3700 of a Labor Code,for the performance of the work for EXISTING GARAGE AT SFR
<br /> which this permit is issued.
<br /> 01 have and will maintain workers' mpetsation insurance,as required by section 3700 of
<br /> the Labor Code,for the performan a of the work for which this permit is issued. My Item Description Tot Fee
<br /> workers'compensation insurance erand policy numberareonfilewith the State
<br /> ----- ------------------------------ ---
<br /> Conn rsLicenseBoard 1010 Imaging/Technology 15.00
<br /> E?fleriify that in the performance of the work for which this permit is issued,I shall not 1017 Plumbing Fee 100.00
<br /> employ any person in any manner so as to become subject to the workers'compensation laws 5030 General Plan Implement 5.00
<br /> of California,and agree that if I should become subject to the workers'compensation
<br /> provisions of Section 3700 of the Labor Code, with comply with these
<br /> provisiit
<br /> ,I Please see reverse side for important information.
<br /> Date IteApplican
<br /> WARNING:FAILURE TO SECURE W RS'COMPENSATION COVERAGE IS
<br /> UNLAWFUL AND SHALL SUBJECT LOVER TO CRIMINAL PENALTIES AND
<br /> CIVIL FINES UP TO ONE IiUNDRE TH0 SAND DOLLARS($100,000),IN ADDITION
<br /> TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR IN SECTION 3706
<br /> OF THE LABOR CODE,INTEREST, ATTORNEY'S FEES.
<br /> CONSTR CTION LENDING AGENCY
<br /> 1 hereby affirm that there is a constructi lending agency for the performance of the work for which
<br /> this permit is issued(Sec.3097,Civil Code).
<br /> Lenders Name _ Address_ _
<br /> City/State.....__ ___Phone
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> I 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 building structure,acatfolding falsework,or demolition or dismantling thereof,will be
<br /> more an thirty-six (36)feet high.(Chap.3.2,Grp.2,An.2,Sec 341,Titlell,CAC.)
<br /> r1'' s 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 /> Division of Industrial Safety Permit No.
<br /> I certify that I have read and state that the information 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 -described property for inspection purposes.
<br /> Signature of Legal Owner or Auth
<br /> Date '2�'1 1 Appllcnl
<br /> Accepted:JAA Approved:JAA p•ed Date:12/04/2017 Issue Date: 12/04/2017 APN:242-050-04 Valuation:$0.00 SgFt 0
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