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HomeMy WebLinkAbout0 �-.---��.-�-.._... - _____._�.�.�� �. �� WORKERS'COMPENSATION DECLARATION A;PPLtC,�it'Bf�. � i'�.Cl��fiG► P� � I hereby offirm tkat I hpve a certificole of consent 1c self 76A6m7A � insure,or a cert'ificate of Workers'Comp n�tion insurance, CE BI7(REV.1Di81) � or p certifiad copy thereof(Sec,3800,lab.C.) EpWp►.TY QF tOS AkNG$!E'b� , BU1413(N6 AWD SAFETY �`�� �� Pollcy No. ""� Company��il� . — � Cerrified copy is hereby furnished, poa nPPliCanli To F�ll�N(PRirtr oR rvPEy ����'� � � Certified mpy is filed wirh the caunty 6ullding inspec- p���= tion depariment. NUM9[R FlxiuREOR IiLM (�/ FfE LOEkll7Y - YYATEA CL05f7 . Oo-te A�plicani ryµp��f �. CERIIFICATE OF EXEMPTION PROM WORIEER5' Bd�iH iUe ���'�T- COMP@ti5ATl0ldIN5URkNCE � . "— � �����!,,wr.�.�� (FhiE iroF 6.cwwp{•tad i4 th.work Imrof�.d M�r . _ ow�NE--�'� I t� ��LF a�IM hwl�V�Ij111{Ww(�'1�M IYy.� LFNATORY � . MAit 9 ADDRE55 I cartify thpr in the performpr�ce of Ihe wwk for which this permit is iseued,I shall not employ any person,in any manner � CIN so as to k»come subjod to the Workers'Compensafion lows. �ISHWASHER < � CONTRq{TOR � �afe Applican� CLOTtifS WASH[R �. IdOTICE TO APPLICANT: If, ofler moking thls Certificate of SWIMrtiINGPOOtRECEr'TOR � � ���� � �� � Exemp^ion, you should be:ome subject to the Worker.s' CI7Y TEL N�J ', Compensatian provlsions of the Labor Code,you muet 4orfhi- �qyyN SPRi.NKLER SYSTE61 - �� with cornply with such provisions or this prrmit shdll be � STATE t`ertl�� LIC. deer»ed ra�oked. WATER HEATER ' �ICENSE NO. t��'a�' . S6. � LICERJSFD CONTRACTORS UECLARAiION — DiSi ��N4 PIEOce55e0 av � 1 hereby o9firm rha�I om licensed under provislons of Choprer 9 GRS SYSfiiM qllTLGTS , � (comme�cing wilh Sedion 708�)of Division 3 of ihe Bu:iness OUTL[ibOVCR� i- � ond Proibssions Coda,and my license is In full force and effect. 5 PEit SvSTeM � �FINAL ���� r�[� DA7E u�RA_T1QN aJ Licanse Number �� Lic Class �*� � — � FINAL [,� � Controctor Dafe � �8Y i � I am exempt under Sec _ t"� . � B.&P.C.for this reason plan check fae � c� Doie: PLUMBING PEiNu41T ISSUING FEE$ .. Signalure � �" � TOTALFEE x� � Ploncheckapplicc�h - . � SINGLE FRA+dLY — HOM€OWNER-BUILDER DECLARATIpW Name � , I here6y offirm thot I om eaempt from Ihe Contractor's License Ad�ress '�4.._. � M' Low for fhe following reason (Secfion 7031.5, &usiness and Proiesaiows Code. '••�:. . �� City iel.No. - �� i ❑ I,as owner of ihe properry,will do�he work and the . . " a�+,; 4 (�.i skutiwe is nat inrended or offe.ed fo�sole (Sect��on - 7�1��i�eo��+�.CaA). � . . � � t' +�",4.� .;(�,�. COMISFRUCTIOW LENBMIG AGENCY - � '- 1 herehq vif9.m fFat Ihere is a coRskuction landing ogency for �� �'�•j. �"����` ihe�7mbmowew of ih.wo�k f«which this psrmit is iwuad � . . �ar.�7►,6;..ff.)-. - . . � Lawdlv's Ncvae � _ •. Lender's Ad�ress - I certify Ihat I hcve reod this appliwfion and srale thol 1he � a6ove inferrwaHe`i Is correct.I ogre�to cow��sky wiFh oll County ordirtemces ond S%se lows rsguloting%um6ing,ond he�eby � . auihorize rapresentotives of Ihis County to enler upen the �. above-mentlaned property for Inspecrion purposes. SE@ RBUERSE P�R E%PLAI�4ATtfRN L�4#ICsk►i►6E.. Si�rwlw.e a€ Defe � - ' � — � �. � � ,�* _ �----- •.,r �. ��^,���� ,4.,t � � *�'` �� � iy R_ i�� y"•�� �y . r'��,i..�`�"_ w war . +�f � ___ ._ _ _._ - - _ � ...�_.... __r ..�. _ �uVL _. _ �►