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' CITY OF TRACY PERNUT APPLICATION ' COMMUNITY DEVELOPMENT DEPARTMENT PART 1 520 Tracy Blvd,Tracy, CA 95376 (209) 831-4600 Fax No (209) 8314606 Inspection Request Line (209) 8314621 BUILDING PROJECT IDENTIFICATION LICENSED CONTRACTOR DECLARATION- ffi 9808-0372 1 hereby arm under the penalty of perjatry that I am licensed under provisions of Chapter 9(commencing APPLICATIONlPERMTT NUMBER with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect 271166 C12 C21 2/28/99 ' STREET ADDRESS 541 W GRANT LINE RD License R License Class Expiration Date APN cr r' Date 214-490-04 OWNER BUILDER DECLARATION- ' (Sec 70315 Business and Professions Code) Any city which requires a permit to construct alter improve DESCRIPTION OF WORK demolish or repair any structure prior to its issuance also requires the applicant for such permit to file a DEMOLISH BUILDING,SLAB,&FOUNDATION signed statement that he or she is licensed pursuant to the provision of the Contractors License Law (Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031 5 by any ' applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500) I hereby affirm under the penally of perjury that I am exempt fro the Contractors License Law for the following reasons PROPOSED USE _I,as owner of the property or my employees with wages as their sole compensation will do the work OR OCCUPANCY and the structure is not intended or offered for sale(Sec 7044 Business and Professions Code The Contractors License Law does not apply to an owner of property who builds or improves thereon and who VALUATION $4,500 does such work himself or herself or through his or her employees provided that such improvements are not OF PROJECT ° intended or offered for sale If however the budding or Improvement is sold within one year of completion the owner builder will have the burden of proving that he or she did not build or improve for the ' OWNER CITY OF TRACY purpose of sale) _I,as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec 7044 Business and Professions Code The Contractors License Law does not apply to an owner of TRACY CA 953760000 the property who builds or improves thereon and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law) PHONE ( ) FAX _I am exempt under Sec Business and Professions Code for this reason CONTRACTOR MODESTO SAND&GRAVEL 6137 HAMMETT RD Owner Date MODESTO CA 94538 (249)545-4425 ( ) _ -WORKERS'COMPENSATION DECLARATION- i ' PHONE FAX I hereby affirm under penalty of perjury one of the following declarations STATE LICENSE NUMBER 271166 _I have and will maintain workers compensation insurance as required by Section 3700 of the Labor CITY BUSINESS LICENSE NUMBER 36472 Code for the performance of the work for which this permit as issued My workers compensation insurance ENGINEER or ARCHITECT carrier and policy number are (This section need not be completed of the permit is for one hundred dollars ' ($I00)or less) Carver STATE FUND Policy Number 1520219-98 Expiration Date 7/1199 _I certify that in the performance of the work for which this permit is issued I shall not employ any person m an manner so as to become subject to the workers compensation laws of Callfomia and agree t PHONE ( ) - FAX ( ) - that if I sh 1 become sit �hhcise o the, orkers compensation provisions of Section 3700 of the Labor Code I shall fo wi c mply visions APPLICANT Applicant Dam { MODESTO SAND&GRAVEL 6137 HAMMETT RD WARNING FAILURETOSECU WORKERSCOMPENSATION COVERAGE ISUNLAWFUL AND MODESTO CA 94538 SHALL SUBJECT AN EMPLO RTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(S100 000) IN ADDITION TO THE COST OF COMPENSATION PHONE (209)545-4425 FAX ( ) - DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE INTEREST AND ATTORNEYS FEES ' I CER'T'IFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE SHOWN INFORMATION IS CORRECT AND THAT I AM CONSTRUCTION LENDER THE OWNER OR DULY AUTHORIAGENT OF THE OWNER —Applicant affirms under the penalty of perjury that there is a construction lending agency for the I AGREE TO COMPLY WITH ALZE CITY AND STATE LAWS performance of the work for which the permit is issued(Section 3097 Civ C) ' RELATING TO WILDING CO S RU ON I HEREBY AUTHORIZE Lenders Name Address REPRESENTATIVES OF THE IT OF CY TO ENTER THE ABOVE _Applicant affirms under the penalty of perjury that there is no construction lending agency for the MENTIONED OPERTY I N PURPOSES performance of the work for which the permit is issued(Section 3097 Ca C) ' SIGNATURE -IMPORTANT- ft Application is hereby made to the City of Tracy Community Development Department for a permit subject DATEto the condition and restrictions set forth on this application and all applicable city and state laws and UOWNE L4/CONTRACTOR ordinances 101 Each person upon whose behalf this application is made and each person at whose request and for whose ' 0 AGENT FOR OWNER 0 AGENT FOR CONTRACTOR benefit work is performed under or pursuant to any permit issued as a result of this application agrees to and RECEIVED BY , DATE $/31!98 shall indemnify and hold harmless the City of Tracy its officers agents and employees in accordance with all applicable city and state laws and ordinances 2 Any Plan Review becomes null and void after ONE HUNDRED EIGHTY(190)days from the data of 000 this application PLAN CHECK DEPOSIT RECEIPT NOTE A VALID PERMIT RESULTS WHEN PART If IS ISSUED BY THE CITY OF TRACY COMMUNITY DEVELOPMENT DEPARTMENT DISTRIBUTION WHITE PROPLRCY i 1LL PINK OWNLPJAPPLICAN I APHL 199.