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DEVELOPMENT SERVICES DEPARTMENT s Mentoca. Building Safety Division um..� BUILDING PERMIT ISSUANCE APPLICATION PERMITNUMBE9 - ADDRESS - 22-3444 2500 Daniels Street, Manteca, CA 95337 IDENTIFY WHO WILL PERFORM a UCEN$ED.CONTRACTDR 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 license Is In full force and effect. LICENSECLASS - LICENSE NUMBER ' -- LICENSE EXPIRATION - B 712129 9/30/23 SIN TURF _ ..:... ..:::... DATES 9112/22 b WNER-BUILDERDECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason (Sec. 7031.5 Business and Professions Code). Any city or county which requires a permit to construct, alter, Improve, derrollsh or repair any structure, prior to Its Issuance also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provlslons of the Contractors Chapter 9 (commencing with section 7000 of Division 3 of the Business and Profession's Code) or that he Is exempt therefrom and the basis of the alleged exemption. Any violation of Section 7031.5 by anyapplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500), 0 I, as owner of the property, or my employees with wages as their sole compensation will do 0 all of or 0 portions of the work, and structure is not Intended or offered for sale (Sac. 7044. Business and Professions Code, The Contractors Ucense Law does not apply to an owner of property provided that such Improvements are not Intended or offered for sale. If, however the bul King or Improvement Is sold within one year of completion, the Owner -Builder seket will have the burden proving It was not built or Improved for purpose of sale). one 01, as owner of tha 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 property who builds or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License law. ❑ 1 am exempt under the Contractors' State Ucen ser Law for the following reason: By my signature below I acknowledge that, except for my personal residence In which I must have resided In for at least one year prior to completion of the Improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder If It has not been constructed In Its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the B&P Code Is available by request or online. Property Owner/Authorized Agent Signature Print Name Date WORKERS' COMPENSATION DECLARATION I hereby affirm under the penalty of perjury one of the following declarations: 01 have and will maintain a certificate of consent to self -insure for workers compensation, Issued by the Director of Industrial Relations as provided for by section 3700 ofthe Labor Code for the performance of work for which this permit is Issued. Poll Number: B I have and will maintain workers' compensation Insurance as required by section 3700 of the Labor Code, for the performance of work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Stale Fund 9180608.21 101112022 Carrier Policy Number Policy Explration Date Name of Agent ® Icertify that, In the performance ofthe work for which the permit is Issued, I shall not employ any person In any manner, so as to become subject to workers' compe satlo laws of California, and agree that, If l should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, l shall fort h p ithth aprovisions. John D. Minaudo 9112122 Sign re Print Name Date WA NTNG: FAILURE TO OBTAIN WORKERS COMPENSATION INSURANCE COVERAGE IS UNLFAWUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. DFCLARATION REGARDING CONSTRUCTIONLENDING I hereby affirm under the penally of perjury that there is a construction lending agency for the pedormance ofwork for which this permit Is Issued (CMI Code Sec. 3097). Lenders Name Lenders Address Dl CLARATION BY CONSTRUCTION PERMIT APPLICANT lam: 11 The Property Owner(requires separate verification form) 0Authorized to Act on Property Ownees Behalf (requires separate authorization form) IN ACalifornia Ucensed Contractor By my signature below, I certify to each of the following. I certify that I have read this application and state that all Information Is correct. l agree to complywith all city and county ordinances and state laws relating to building construction, and hereby authorize representatives ofthe City to enter upon the above-mentioned property for Inspection purposes. I understand that approval of a permit does not signify compliance with the American with Disabilities Act, I agree to save, Indemnify and keep harmless the Cl Man ca against liabilities, Judgments, costs nd expenses which may accrue against sahl City on consequence of the granting of this permit. y �. ,,� 9112122 Sign re Date