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FROM : , MCK I NLEY
<br />
<br />PHONE NO. : 8355156 May. 27 2011 12: 52PM P3
<br />BUILDING PROJECT IDENTIFICATION
<br />11-‘1241 1
<br />.. APPLICATION/PEWIT NUWER-
<br />. w
<br />1690 N TRACY BI- cl
<br />i,
<br />PROJECT
<br />STREET ADDRESS C 2390014o APN
<br />------- C
<br />DESC R.I PTION'OF WORK d
<br />INSTALL SAFETY COVER-VGB
<br />REQUIREMENT l'
<br />a
<br />a
<br />II
<br />PROPOSED USE
<br />OR OCCUPANCY
<br />-I
<br />VAWATION S' 1,395A0 i
<br />OP PROJECT i
<br />OWNER • PIPER, •I ERT PE Lk KAREN
<br />2101 GOLDSTRIla RD (
<br />SAN ANDREAS CA 95249
<br />1
<br />••':. • (209)754-4787 1
<br />PHONE FAX 1
<br />SPA iviAsTnts INC
<br />NTRACTOR PA), BOX 14322
<br />FRE1V1ONT CA 94539
<br />41
<br />MONS 641)b046
<br />STATE LICENSE NUMBER
<br />CITY BUSINESS LICENSE NUMBER 35739
<br />ENGINEER or ARCHITECT
<br />1
<br />0
<br />PHONE FAX
<br />i. APPLICANT PAM BARRETT
<br />i 1690 N TRACY BLVD- #7
<br />.... TRACY CA 95376
<br />7100
<br />--
<br />....PHONE (209)1135-.5156 FAX
<br />AP
<br />.
<br />I CERTIFY THAT I HAVE READ THIS APPLI-CATION. AND STATE
<br />HAT THE SHOWN INFORMATION IS CORRECT, AND THAT) AM
<br />THE OWNER* OR DULY AUTHORIZED AGENT** OF TILE OWNER,
<br />I AGREE TO COMPLY WIT' I ALL CITY AND STATE LAWS
<br />RELATING TO BUILDING CONSTRUCTION, I HEREBY
<br />AUTHORIZE REPRESENTATIVES OF THE CITY OF TRACY TO
<br />ENTER THE ABOVE ENTIONED PROPERTY FOR INSPECTION
<br />PURPOSES. *Requires, s panne verifluuti unit. ** requires separate
<br />authorization form. ..` ; --.,
<br />SIGNATUR 0 • :
<br />PIN'. , ,
<br />DAI:'
<br />0 OWNF.R• 0 CONTRACTOR
<br />1)qGENT FOR OWNER** 0 AGENT FOR CONTR.ACIOR
<br />RECE—IVED
<br />K
<br />BY( _, ( ., DATE
<br />.13h(0//L,
<br />DEVELOPMENT AND ENGINEERING SERVICES
<br />333 Civic Center Plaza, Tracy, CA 95376
<br />Phone (209) 831-6400
<br />Fax No. (209) 831-6439
<br />In spectinn Retittftt Line (209) 831-6440
<br />- LICENSF.D CONTRACTOR DECLARATION-
<br />hereby affirm under the penalty of pedury that I ton liceosed under provisions of Chapter 9 (commencing
<br />tft Section 70066t4gon 3 or the Business ang Professions Code anti my Iteicylitipi cull force end
<br />'feet.
<br />icense # License Class Expiration Date
<br />ontr.teter_
<br />OWNER-/WILDER DECLARATION-
<br />cc 703 IS. Business and Profexsiont Code) Any city which requiret a permit to construct, alter, OnprOve.,
<br />ernolish, or repair any structure prior to its issuance, also requires the applicant for such Permit to tile a
<br />gned statement that lie or she is .licensed pursuant to the provision of the Contractors State License Law
<br />Chapter 9 (commencing with Section 700(1) of Division 3 of the Business and Professions Code), or that he
<br />r she is exempt there from and„the basis for the alleged exemption. Any violation of Section 7031.5 by any
<br />pplicant for a permit subjects this applicant to a civil pentiltY of prit more than live hundred dollars ($500). I
<br />creby affirm undue the penalty of perjury that I am exempt 11-o the Contractoot License Law for the
<br />eon(s) indicated below by the checkmarks(s) I have placed next to the applicable item(s).
<br />I, as owner of the property. Or my employees with weep: as their sole compensation, will do ) all of or
<br />) portions of the work, and the structure is not intended or offered for sale (See. 7044, Business and
<br />efessions Code, The COntfaCtOrS Licence Law does not apply TO an owner of property Who builds or
<br />mproves thereon, and who does such work himself or herself or through his or her employees, provided that
<br />uch improvements arc not intended or offered for sale. If, however, the building or improvement is sold
<br />within one year of completion, the owner-builder will have the bunko of proving that he or she did not build
<br />r improve for the purpose uf sale.)
<br />, I, as owner of the prone-ay, am exclusively contracting with licensed contractors to construct the project
<br />Sec. 7(154. BUSineSS and RrofeesiOna Code, The Contractors License Law does not apply io an owner of the
<br />property who builds Of Improves thereon, and who contracts for such projects with a contractor(*) licensed
<br />ursaant to the Contractors License 1.aw)
<br />I am exempt der Sec.
<br />- WORKERS' COMPENSATION DECLARATION
<br />hereby affirm under penalty of perjury one of the Rillowing declarations,
<br />I have and will maintain workers' compensation insurance, as required by Section 1700 of the Labor
<br />Code, for the performance of the work for which this permit is issued. My workers' compensation insuntrux
<br />earner and policy number are: (11)is section need not t•te completed lithe permit is for one hundred dollars
<br />($100) or less)
<br />STATE COMP FUN] 1850540 7/1/2011
<br />aiTiot Policy Number Expiration Date
<br />I certify that in the performance of the work for which this permit is issued. I shall nOt employ any
<br />person in any manner to as to become subject to the workers' compensation laws of California, and agree
<br />that lit should hecinytilubject to the workers' compenSation provisions Serai en 3700 of the Labor Code, I
<br />shall fortheith oornPly ith those provis. 5
<br />\
<br />P
<br />O .>•4, applicant IM
<br />et.
<br />WARNING: FAILURE'. TO SECURE WORKERS' COMPENSATION t,!OVERAGF. IS UNLAWFUL,
<br />AN1) SHALL SUBJECT AN EMPLOYER TO CRIMINA L PENALTIES AND CIVIL FINES UP TO ONP.
<br />HUNDRED THOUSAND I7O1.1,.A RS ($100,(l00), IN ADDITION TO THE C:OST OF COMPENSATION.
<br />r)AmmIlig AS PROVIDED FOR IN SECTION 3706 OP THE LABOR CODE, INTEREST, AND
<br />ATTORNEY'S P.P.F.S.
<br />-CONSTRUCTION I,KNDING AGE.NCY-
<br />Applicant iinirrn% under the penalty of perjury that there is 3 construction lending agency for the
<br />performance of the work for which the permit is issued (Section 3097, Civ. C) Lender's
<br />Name Address
<br />, Applicant affirms under the penalty of perjury that there is no construction lending agency Our thr
<br />performance of the work for which the permit is issued (Section 3097, Civ. C)
<br />- IMPORTANT-
<br />Application is hereby matte to the City of Tracy Department of Development and Engineering Services Ike a
<br />permit subject to the condition and restrictions set Forth on this application, and an applicable city and state
<br />laws and ordinances.
<br />I. &sub person upon whose behalf this application is made and each person at whose request and for whose
<br />benefit work is performed under or pursuant to any permit issued as a result of this application agrees to, and
<br />shall, indemnify and hold harmless the City of Tmcy, its officent, agents and employees in accordance with
<br />all applicable city and state laws and ordinances.
<br />2. Any Plan Review becomes null and void after ONE HUNDRED EIGHTY (180) days from the date of this
<br />application,
<br />NOTE: A VALID PERMIT RESULTS NVFIEN PART IllS ISSUED RV THE CITY OF TRACY
<br />DEPARTMENT Of DEVELOPMENTAND ENG I NEERINC SERVICES.
<br />Business and Professions Code for this reason
<br />' r
<br />D e Ill 'A; el/e/
<br />Attik
<br />TRACY
<br />CITY OF TRACY
<br />FERM a APPLICATION
<br />PART 1
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