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f CITY OF STOCKTON 1 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request 937-8560 PERMIT App104a0000464iction 111uy LICENSED CONTRACTORS DECLARATION s� I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my �� Address Issue Gat e license is in full force and effect. CONTRACTOR 2615 WATERLOO RD 6/25/04 LICENSE NO. LICENSE TYPE DATE Permit Type UUTSIGE CONNECTION----------2L STOCKTON BUS.LIC.NO. Subdivision , OWNER-BUILDER DECLARATION Parcel Nbr 119 210 0101 I hereby affirm that I am exempt from the Contractor's License Law for the Geo Code 1100 01 07, 24 2 following reason(Sec.7031.5 Business and Professions Code:Any city or county T ETAL which requires a permit to construct,atter,improve,demolish,or repair any structure, OWn e r P1 a(ae B E SD I E:� ANN G T R prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Address . . . 1700 F A I R I N G T ON L 11 Law(Chapter 9 commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged MODESTO CA 953355 exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more that five hundred dollars($500.): Appl Type . . . OUTSIDE CONNECT - SEWER ❑ I,as owner of the property,or my employees with wages as their sole Desc of Work . NON RESIDENTIAL compensation,will do the work,and the structure is not intended or offered for sale SEWER LINE (Sec.7044).Business and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does valuation 0 such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold y' Ud r e f t 0 c o fl l 1 fU within one year of completion,the owner-builder will have the burden of proving that q 9 he did not build or improve for the purpose of sale.) Occup Group Const Type ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to any owner of property who builds or Special Notes a p d Conditions improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) AN ENCROACHMENT PERMIT IS REQUIRED PRIOR ❑ 1 am exempt under Sec. B&P.C.for this TO CONNECTION TO A CITY MAINTAINED reason UTILITY Date owner MI5 ISA PERMIT FOR THE COLLECTION OF SEWER CONNECTION FEES ONLY, A BUILDING PERMIT MUST BE OBTAINED FROM THE COUNTY OF SAN JOAQUIN PRIOR TO THE NOTE: To protest the imposition of any development fee,dedication, COMMENCEMENT OF WORK 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 - - - - - - - - - - - - - - F[E- - - - - - - - - - - - - - - - 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 IF-ADMIN FEE ("),5%) tx i i 16.90 legal theory forming the basis for the protest. !F-WW-EXISTING-:/CAL 4H 400.00 WORKER'S COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self-insure,or a certificate i F W W F!!T!!R E S/CAL A I 840.00 Of Workers'Compensation Insurance,or a certified copy thereof(Sec.WW,Lab.C.) I F-WW-LOMB-S/b A L t AJ 2,100.00 Policy No. Company ❑ Certified copy is hereby furnished.Expires . ;.. ❑ Certified copy is filed with the city building inspection department. PERMIT TOTAL 3,456.90 Date ,Applicant (CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be completed if the permit is for one hundred dollars b ($100)or less. I cer1ify 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 o Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption you should become subject to the Workers'Compensation provisions of the Labor 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.I agree to comply with all city and county ordinances and state laws relating buildin construction,and hereby authorize representatives of this city to enter upo 11 a ve mentioned proQedyforinspe ion pu oses. SIG ADDRESS JOB ADDRESS APPLICATION APPROVAL THIS PERMIT DOES NOT BECOME VALID UNTIL SNED BY THE BUILDING OFFICIAL OR HIS DEPUTY AND FEES ARE PAID. SIGNATURE