HomeMy WebLinkAbout3472WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C. )
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any monrTer
so as to become subject to the ,Workers CompensotiorrLav s,,
Date y € Apphcar�t `— ri '
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS 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.
License Number Lic. Class
Contractor
I am exempt under Sec
B.BP.C. for this reason_
Signature
Date
Date:
SINGLE FAMILY
HOME OWNER -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):
4y I, as owner of the property, will do the work and the
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
(6bove.-mentioned property for inspection purposes.
f „ b
:r
Signature of Permi tee Date
APPLICATION O PLUMBING PERMIT
76A667A
CE 817 (REV. 10/81 )
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
a x
BUILDING zADDRESS
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
1 l I
WATER CLOSET
NEAREST
CROSS ST
BATH TUB
OWNER w s,tF ' s
MAIL
ADDRESS
SHOWER
LAVATORY
SINK
CITY (Q , ,,J JEW,,TEL. N
DISHWASHER
CONTRACTOR
CLOTHES WASHER
ADDRESS '
SWIMMING POOL RECEPTOR
CITY TEL. NO.
LAWN SPRINKLER SYSTEM
—
STATE LIC.
LICENSE NO. CLASS
WATER HEATER
DISTRICT NO.
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL VALI®ATION
FINAL
BY
7Z;
00 A-�
Plan check fee
PLUMBING PERMIT ISSUING FEE $
"/®
U
TOTAL FEE
2-6
5-0
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
C