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CITY OF STOCKTON COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION, CITY HALL PHONE: (209) 937-8561 STOCKTON, CALIFORNIA 95202 24 Hr. Inspection Request 937-8560 PERMITAppl icaC60n Nuj41ber LICENSED CONTRACTORS DECLARATION 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 kense is in full force and effect. Job Address issue Gate CONTRACTOR 2605 WATERLOO RD 6/25/04 LICENSE NO. LICENSE TYPE DATE Permit Type OUTSIDE CONNECTION----------2L STOCKTON BUS.LIC.NO. Subdivision OWNER-BUILDER DECLARATION Parcel Nbr : l 19 210 09 I hereby affirm that 1 am exempt from the Contractor's License Law for the Geo lode 1700 01 0'i 25 2 following reason(Sec.7031.5 Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure, UW h e r Name B E S O T E S ANN G TR EIA L 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 FAIRINGTGN IN 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 95355 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.): Apel Type OUTSIDE CONNECT SEWER ❑ I,as owner of the property,or my employees with wages as their sole valuation . . 0 compensation,will do the work,and the structure is not intended or offered for sale (Sec.7044).Business and Professions Code:The Contractor's License Law does Square fty B Zoning . . . , BBB not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such Improvements Occup G r i u{ Coast Type are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) Special Notes and Conditions ❑ 1,as owner of the property,am exclusively contracting with licensed AN ENCROACHMENT PERMIT IS REQUIRED PRIOR to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to any owner of properly who builds or TO CONNECTION TO A CITY MAINTAINED improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law.) UTILITY ❑ 1 am exempt under Sec. ,BBP.C.for this THIS IS A PERMIT FOR THE COLLECTION OF reason SEWER CONNECTION FEES ONLY. A BUILDING Date Owner PERMIT MUST BE OBTAINED FROM THE COUNTY OF SAN JOAQUIN PRIOR TO THE COMMENCEMENT OF WORK NOTE:To protest the imposition of any development fee,dedication, ---------- reseryation 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 PERMIT TOTAL .VU 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 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 le gal theory forming the basis for the protest. WORKER'S COMPENSATION DECLARATION I hereby affirm that I have a certificate rt consent self-insure,ora certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. 1n�' Company ❑ Certified copy is hereby furnished.Expires "- ❑ Certified copy is filed with the city building inspection department. Date ,Applicant CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE This section need not be completed if the permft is for one hundred dollars ($100)or less. I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date 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 to building con traction,and hereby authorize representatives of this city to enter po the bov entioned property r ins ection pu es. SIGNE '0,A D E PLICATION APPROVAL THIS PERMIT DOES NOT BECOME VALID UNTIL IGNED BY THE BUILDING OFFICIAL OR HIS DEPUTY AND FEES ARE PAID. SIGNATURE