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07/07/2010 12:38 2099433003 APEC PAGE 02/03 CITY OF TRACY TRACY PERMIT APPLICATION DEVELOPMENT AND ENGINEERING SERVICES PART 1 333 Civic Center Plaza,Tracy,CA 95376 Phone(209)831-6400 Fax No.(209)831-6439 Inspection Request Line(709)831-6440 BUILDING PROJECT WENTIFICATION jUCUragrp camriu CrOR DECLARA r101V- I hereby affArm under the penalty of perjury that I am licensed under provisions of Chapter 9(commencing with with Swiun 700ocM1tb)VI force and 3"0 N TRACY BL effect on 5 of the Business anit Profession*Ccdo and my)i at Exp$rAtoo))Date PROJECT 31 Contractor % Ditc:_Z STREET ADDRESS AFN �ro�5R-vw )WZ1.6CMAA770N- (Sec 7031.5.Budoese and Prof;assjoris Code)Any city which squires permit TO alter,improve, DESCRIPTION OF WORK demolish,or repair any structure Prior to its issuance,also requires the applicant for such permit to file a CO"UXT FOR TANK MONITOR SENSOR signed son'tent that be or she is licensed pursuant to%be provision Of the Contractors State License Law (Chapter 9(contragneing with Section 7000)of Vivision 3 of the Business and Professions Code),or that he of itbe is exempt there from and the basis for the alleged exemption.Any violation of Section 7031.5 by 07 applicant for 4 permit subjects the applicant to a civil penalty of not more thein five hundred dollars($500).1 hereby affirm under the penalty of pe4ury that I=exempt fro the Contractors License Law for the resson(s)indicated below by the checkmarloi(s)I have placed next W the Applicable item(s). PROPOSED USE OR OCCUPANCY 1,as owner of the property,or my employees with wage.'as their sole compensation,will do Q all Of or s portions or me work,and the structure is nut b0t3k4od of offered for sale(Sec.7044,Suaint s and VALUATION $2,500-00 Professions Code.The Contractors License Law does not apply to an owner of property who builds or OF PROJECT improves thereon,and who does such work lAmself or herself Or through his or Isar waploYcob,Provided that such iraprowments are not intended or offered for sale.if,however,the building or improvement is sold OWNER --JULrrLA, ER widila we year of completion,the owner-builder will have the burdim or pruving and he ur alm did not build 3940 N TRACY BLVD or Improve for the purpose of sic.) TRACY CA 95M 1,as owner of the property,am exclusively contracting with licensed o0iincM to construct the project (Sec,7044.13usloea$and ftoteSS1,0115 Code,The Contractors License Law does not VPIY to an owner of die property who builds or improves thereon,and who contracts for such projects with 8 contractor(s)licensed PHONE FAX purinuont to the Contractors License Law.) I am exempt under Z5ec._Business and Profcssions.Code for this reason CONTRACTOR P.0 BOX 55105 3T ON CA 95205 Owner Date.-- -W0RfiERS'COM.PMVJA 7101V DECLARATION- (209) ECLARATION-(209)943-3000 1 licmby affirm under penalty of prijury mic oftlic,following declarations, PHONE 375 STATE LICENSE NUMBER I have and will maintain workers'compensation insurance,as roquirod by Section 3100 of the Labor CITY BUSINESS LICENSE NUMBER ZWo,for the perflormance of the work for which this permit is issued.My workers'compensation insurance carrier and policy numberare:(This section need not be completed if the permit is for one hundred dollarsEN—GINEER or ARCHITECT (S 100)or less) Carrier STATE COMM FUN] Policy Plumber Z384M5332 )Expitstjon Date 110011 I certify that in the petfonimoc of the work for wWcb this permit is issued,I shall not employ any pW—cfi in any manner so as to borom subject,to the workers'compensation laws of California,and ngrut PHONE FAX that:if I should become subject to the workcrV compensation PyOvisiOfls Of Section 3700 of the Labor Code,I shall forthwith comply with those isions, Wt APPLICANT ApEC 11 -7- 7 Date r-0 BOX FAI 05 Applicant STOE=. ON CA M05 WARNING: FA113JR5 TO E WORKERS,COMPENSATION COVERAGE IS UNLAWFUL, AND SRALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNL))?.F.I)TT401JSANT)DOLLARS(SIOD,000).Nj ADDITION To THE COST OF COMPENSATION. PHONE (209)943-3000 FAX DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE -coN.TTRIXTION LENDING AGENCY- THAT THE SHOWN INFORMATION I$CORRECT,AND THAT I AM Applirarit;affirms under the penalty of pc�ury that there is a construction lending agency for the THE OWNER*OR DULY AUTHORIZED AGENT"OF THE OWNER. performance of the work for which the per6t is issued (Section 3097, Civ. C) Lenders I AGREE TO COMPLY WDE ALL CITY AND STATE LAWS Name Address_ RELATING TO BUILDING CONSTRUCTION, I HEREBY AUTHORIZE REPRESENTATIVE F THE CITY OF TRACY TO _ApplieW affirms under tbo penalty of perjury that there is no construction landing agency for the ENTER THE ASOVIP ,�MF 5,;NTIQ��OPERTY FOR INSPECTION performance of the-ork for which the permit is issued(Section 3007,Civ.Q f, Cation fom. 00 requires separate PURPOSES. RrOTHT -01PORMNT authori-,�, Application is hereby made to the City Of Tracy Department of Development and Engineering Services for a permit subject to the condition and restriedow set forth On thiq application,and all applicable city and gate SIGNATURE /J laws and Ordinances. I.Each person upon whose behalfthis application i,%made and cath Denson at whose request and for whose P RIN T NAME: Pc--rAA htg� benefit work is V&omied under or pursuant to any permit issued as a result of this application agrees to,And shall,indemnify and hold harmless the City of Tracy,its officers,agents and cropityees in accordance with DATEall applicable city and state laws and ordinances. 0 OWNER" 16 CONTRACTOR 2.Any Plan Review becomes null and void after ONE JIUNDRED EIGHTY(180)days from the duc Of this application. 103 AGENT FOR OWNER" 0 AGENT FOR CONTRACTOR IVEP, DATE PERMIT RESULTS WHEN PART 11 IS ISSUED BY THE CITY OF TRACY ��Y` % -7--7 NOTE, A VALID DEPARTMENT OF DEVELOPMMI'AND ENGINEERING SFAVICE&