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WORKERS' COMPENSATION DECLARATION
20-0026
1 hereby, affirm that I have a certificate of consent to self in- 76A667A DPW 4/87
sure, or a certificate of Workers' Compensation In ura ce, or a CE 817 (REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.) (%� �/L� ply
- Company.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is filed with the county building inspection
department.
NUMBER FIXTURE OR ITEM @ FEE
Date Applicant
WATER CLOSET (TOILET)
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB
COMPENSATION INSURANCE
SHOWER
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
LAVATORY
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so
SINK
as to become subject to the Workers' Compensation Laws,
DISHWASHER
Date Applicant
CLOTHES WASHER
N�7 " E TO APPLICANT: If, after making this Certificate of Ex-
SWIMMING POOL RECEPTOR
e m, you should become subject to the Workers' Compen-
satwn provisions of the Labor Code, you must forthwith comp-
LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok-
ed.
WATER HEATER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
GAS SYSTEM OUTLETS
9 (commencing with Section 7000) of Division 3 of the Business
OUTLETS OVER
and Professions Code, and my license is in full force and ef-
5 PER SYSTEM
Ject.
License Number/ 3PY Lic. Class Ca 7
Contractor fi(L� ate 3
I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE $ /o
Signature
TOTAL FEE ;
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
Plan check applicant
I hereby affirm that I am exempt from the Contractor's License
Name
La, `-,r the following reason (Section 7031.5, Business and
Pr,,,ions Code):
Address
I, as owner of the property, will do the work and the
City Tel. No.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above -mentioned property for inspection purposes.
Signature of Pq6lnittee Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
DEPT. OF PUBLIC WORKS
BUILDING ``qq
ADDRESS n(.
LOCALITY ow -
NEAREST
CROSS ST. n
OWNER
MAIL
ADDRESS
CITY TEL. NO.
CONTRACTOR
ADDRESSZ�
CITY /_7✓i-
TEL. NO.�i7 <
STATE y�
LICENSE NO ���7E
LIC.
CLASS
DISTRICT NQ
Co
PROCESSED BY
FINAL VALIDATION
DATE �� vr-
FINAL / /
BY �t d,
11
0
0
Q
Z
APPROVALS
DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
-
GAS PIPING
_--
GASVEN(_
HOT WATER HEATER
PI..UP. iNG FIYTURES
_
k GAS PEST
T�
U I IL.I _(,NOTIFIED
FINAL
ffniep on -?Pont
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTE
INSPECTOR'NOTOWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
- ---_- License Law for the following reason (Section '.7031,5,
Business and Professions Code). Any city or county
v..- which requires a; permit to construct, alter, Improve,
demolishorrepair 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 provisions
of the Contractor's License Law (Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pro-
fessions Code) or that he Is exempt therefrom and the
basis for the alleged exemption. Any, violation of Section
dollars ($500k.
❑ I, as owner of the property will do the work, and the
structure is not Intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Law does not apply to an owner; of property
who builds or Improves thereon, and who does sr fork
himself provided that such, Improvements are not ...,end-
ed or offered for sale. If, however, the building or Im-
provement is sold within` one year of completion, the
owner -builder will have the burden of proving that he did
not build or Improve for the purpose of sale.)
I am exempt under Sec.
E & P.C. for this reason
Owner