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i DocuSign Envelope ID:B3F7B888-754D-4763-8E49-4B3295A5BA89 INTY FIRE AU'T'HORITY COMMUNITY RISK REDUCTION DIVISION CONSTRUCTION PERMIT 835 N.Central Avenue,Tracy,CA 9537E vTtf cur�F Phone(209)831-6707 PART I Inspection Request Line(209)831-6736 �JRB f PROJECT IDENTIFICATION -LICENSED CONTRACTOR DECLWATION- APPLICATION/PERMIT NUMBER F22-0099 I hereby off inn under the penalty of perjury that f tint 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 laid effect. STREET ADDRESS:3250 W GRANT LINE RD License N:804431 License Class:A B HAz Expiration Date:81,31/2023 �...„' APN:23860006 Commctor Name�giltt��p((i„g Dater 3/22/2022 DESCRIPTION OF WORK: -OIVNER-BUILDER DECLARATION- Costeo:Temporary Veeder-Rook Monitories Panel (Sec 31.5 Business raid Professions Code)Any city which requires n pcnmit to construct,niter,improve,deal,,? ,or PROPOSED USE OR OCCUPANCY: rcpair an tnhchue prior to its issuance,also requires the applicant for such permit to file a signed statement he or site is license ursurut to tic provision of the Contractors Sime License Liw(Chapter 9 teomntencin• ' t Section 700()of Divitim of rite Business and Professions Code),or that he or she is exempt there from a to basis for the VALUATION OF PROJECT:$0.00 alleged exemption.A violation of Section 7031.5 by any applicant fora peotit subjects dw scant to a civil penalty of not more than • hundred dolltnrs(S5t)O).I hereby affima undcr the pcnitity of it ry that f am exempt OWNER: from Ute Contractors License •w for the reasons)indicated below by the checkmar s)1 have placed next to the applicable itenta(s). COSTCO WHOLESALE CORP, _1,as owner of the property,or my employees 'h wages rias iltei a compensation,will do O all of or PHONE:4253138100 FAX: (}portions of the work,and the structure is not laic d or o ed for sale(Sec..7044,Business and Professions Codc.Tire Contricim s License Law does nut apply to tier of property who builds or improves thereon,;aid who CONTRACTOR: does such work himself or herself or through his or h• -trip es,provided iltafsuciiimprovements:uc nut intruded or offered for sides,If,however,the building or rovenhcnt is within one year of completion,(lie owner-builder JONES/COVEY GROUP INC will have the burden of proving that he orsl id nut build or improt or the purpose of sale.) 1,ns owner of Ilse property,am tisivcly cot7Rdelimg With licemxcd comm rs to construct Iiia project(Sec.7044. j PHONE:8889727581 FAX:9094840300 Business and Prolessions C . he Contractors License Law does not apply to at weer of rite property who builds or improves thereon,and o contracts for such projects with a contractot(s)licensed ort to the Contractor s STATE LICENSE NUMBER:804431 License Law.) CITY BUSINESS LICENSE NUMBER:06008098 �1 ilia ex t under See. Business and Professions Code for this reason r D ENGINEER OR ARCHITECT: tieate IVQRKERS'COMPENSATION DECLARATION- BARGHAUSEN CONSULTING ENGINEER 1 hereby of inn under penalty one of Ilia following declarations. PHONE•2069626611 FAX.4252518782 XI have and will maintain workees compensation insurance,its required by Section 3700 of the Labor Code,for the pcifommnce of the work for which this pennit is issued.My workers compensation insurance carrier and policy number are:(This section need not be completed if the pemtit is for one hundred dollars(SI00)or less) APPLICANT: Canicr.STARSTONE NATIONAL TNS CO Policy Number.T1021 1051 Expiration Date 5/[12022 STEVE NELSON _J certify that in the perfumtance of the work for which this permit is issued,I shall not employ tory person in any umnner so as to become subject to the workers'compensation Imus of California,and agree that if[.should become PHONE•4252516222 FAX subject to lite worker's compensation provisions of Section 3700 of Ilia Labor Code,I shall forthwith comply with those provisions. 3/22/2022 I CERTIFY THAT I HAVE READ THIS APPLICATION Applicant (-f�irl�.(ttldrs Dntr AND STATE THAT THE SHOWN INFORMATION IS CORRECT AND THAT I AM THE OWNER`OR WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE DULY AUTHORIZED AGENT”OF THE OWNER,I HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION AGREE TO COMPLY WITH ALL CITY AND STATE DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S LAWS RELATING TO BUILDING CONSTRUCTION.I FEES. HEREBY AUTHORIZE REPRESENTATIVES OF THE -CONSTRUCTION LENDINGAGENCY- CITY OF TRACY TO ENTER THE ABOVE MENTIONED PROPERTY FOR INSPECTION Applicant alfimts under dee penalty or perjury that there is a construction lending agency for Ute perromunce of trate verification f01T11, the work for which the permit is issued(Section 3097,Civ.C)Lender's PURPOSES.*Requires separate Name Address-____ **requires separate authorization form. SIGNATURE( x(14`” ,((art X Applicant affirms under the penalty of perjury that there is no construction leading agency for ilia performance of the work for which the pemtit is issued(Section 3097,Civ,C) PRINT NAME Ellen Collins .1,IIPORTANT- 3/22/2022 Application is hereby made to the South San Joaquin County Fire Authority's Community Risk Reduction Division for DATE a hermit subject to ilia condition and restrictions set forth on this application,and all applicable city and state laws:aid ordinances, OWNER* X CONTRACTOR I.Each person upon whoseMiadf this application is made and each pehson at whosa request and for winosc IencGt work is perforated under ur pursuant to nay tenni[issued as a result of this application agrees to,a nd employees in AGENT FOR — AGENTFOR accordance with all applicable city and state laws and ordinances. 2.Any Plan Review becomes cult and void after ONE HUNDRED EIGHTY(180)days front ilia date of this OWNER" CONTRACTOR application. RECEIVED BY: DATE: NOTE:A VALID PERMIT RESULTS WHEN PART 11 IS ISSUED BY THE SOUTH SAN JOAQUIN COUNTY FIRE AUTHORITY COMMUNITY RISK REDUC'T'ION DIVISION.