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PERMIT CITY OF LODI-COMMUNITY DEVELOPMENT DEPARTMENT-Building Inspection Division-(209) 333-6714 ----------------------------------------------------------------------- --------------------------------------------------------------------- Permit Number. 20192815 Date Issued:November 14, 2019 Job Address: 625 N SACRAMENTO ST APN: 04119023 Subdivision:Lot No: 1 Owner: DBL RENTALS LLC Owners Address: 701 S HAM LANE,SUITE C LODL CA 92542 Contractor: ADVANCED GEOENVIRONMENTAL INC Phone:8005119300 State Lie.No.: 8487 Contractor Address: 837 SHAW ROAD STOCKTON,CA 95215 '---- Scope o5;1 rk: Removal of(1)500-gallon underground storage tank. Total Sq.Ft.: 0 Valuation 5000.00 Construction Type: No.Stories N/A No.of Bdrm:. N/A Occupancy: U Zoning: LIGHT INDUSTRIAL AND WAREHOUSING Type of Project: DEMOLISH Plan No: N/A ----------------------------------------------------------------------------------------------------------------------------------------- --- Licensed Contractor Declaration:I hereby affirm under penalty of perjury that I am Owner-Builder Declaration:I hereby affirm under penalty ofperjury that I am licensed under provisions of Chapter 9(Commencing with Sec.7000)of Division 3 of exempt from the Contractors License Law for the following reason(See.7031.6 the Business and Professions Code,and my license is in full force and effect. of the Business and Professions Code states any city or coumy which requires a Date: November 14,2019 permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed Contractor: statement that he or she is a licensed pursuant to the provisions of the Contractors License Law(Chapter 9 commencing with See.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 Sec.7031.6 by any applicant subjects the applicant to a civil penalty of not more than five hundred Workers Compensation Declaration:I hereby affirm under penalty of perjury one of dollars($500)). the following declarations: —I,as owner of the property,or my employees with wages as their sole I have and will maintain a certificia[c of consent to self-insure for workers' compensation,will do the work,and the structure is not intended for sale(See. compensation,as provided for by See.3700 of the Labor Code,for the perfomtance of 7044 Business and Professions Code,the Contractors License Law does not die work for which this permit is issued. apply to the owner of a property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided I have and will maintain workers'compensation insurance,as required by Sec. that such improvements are not intended or offered for sale.If however,the 3700 of the Labor Code,for the performance of the work for which this permit is building or improvement is sold within one year of completion,the owner- issued.My worker's compensation carrier and policy number are: builder will have the burden of proving that he or she did not build or improve Carrier for the purpose of sale). Policy No I,as owner of the property,am exclusively contracting with licensed I certify that in the performance of the work for which this permit is issued,I shall contractors to construct the project(Sec.7044,Business and Professions Labor not employ any person in any manner so as to become subject to the workers' Code,and I shall forthwith comply with these provisions owner of property compensation provisions of Sec.3700 of the Labor Code,and I shall forthwith comply who builds or improves thereon,and who contracts for such projects with a with these provisions. contractor(s)licensed pursuant to the Contractors License Law). Date: _I am exempt under Sec. Applicant: WARNING:Failure to secure workers'compensation coverage is unlawful,and Date: shall subject an employer to criminal penalties and civil fines of up to one hundred thousand dollars($100,000),in addition to the cost of compensation,damages as Owner: provided for in Section 3706 of the Labor Code,interest,and attorney's fees. Construction Lending Agency_I hereby affirm under penalty of perjury that there is a construction leading agency for the performance of the work for which this permit is issued. __________________________________________________________________________________________________________________________________ _ 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 construction including,but not limited to the Division of the Occupational Safety and Health Title 8 regulation,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(http://www.dir.ca.gov/title8/indcx/TSindes.aspj <J Contractor i—, Owner Agent for: >J Contractor L_1 Owner Issued by:NE Signature of Contractor,Owner or Agent Date NOTICE THIS PER\IIT WILL EXPIRE BY LIMITATION IF WORT:IS NOT SL\RTED WITHIN 130 DAYS OF ISSUANCE,OR 1F WORK IS ABANDONED FOR NIORE THAN 180 DAYS