HomeMy WebLinkAbout3471WORKERS' 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 t,is
permit is issued, I shall not employ any person in any mash r
so as �to become ,ubject to the Workers' Compensation La'
Date 7 APPlican _ + ✓"
NOTICE/TO PLICANT: If, after aking this Certificate of
Exempfion, 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.&P.C, for this reason_
Signat
Date
76A667A
CE 817 (REV. 10/81 )
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM @
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
5 PER
G—�rz�3Gr✓`
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
Name
I hereby affirm that I am exempt from the Contractor's License
Address
Law for the following reason (Section 7031.5, Business and
Professions Code):
City
❑
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 regula ng Plumbing, and hereby
authorize representatives Af this` Co4lhty to enter upon the
above-mentionecj>proP7 for tnspeyfion purposes.
Sig ature of Perm ttee Date
i
Tel, No.
41 �
BUILDING i
ADDRESS a� 6
FEE
LOCALITY 9
NEAREST
CROSS
OWNER ; 7
MAIL
SEE REVERSE FOR EXPLANATORY LANGUAGE
X0Jff1 q.'A ii73
ADDRESS
CITY
STATE
LICENSE NO.
DISTRICT NO.
/10
FINAL
DATE
FINAL
BY
M
TEL. NO
TEL. NO,
LIC.
CLASS
PRO ESSED BY
VALIDATION