HomeMy WebLinkAbout1673A AfIONDECLARATION APPLICATION FOR PLUMBING PERMIT _ {�
I hereby affirm fhol I have a cerfificafe of consent fo self �yAy��q u
, insure,or a certifim�e of Wo�kers'Compensafion Insurance, CE 8V(REV.1Di87) .
o�o cerrfled wpy thereaf(Sec.3900,l C.) COUNTY OF lQ$ANGE4E5 BUIIDING AND SAFETY
Poliry N��Com�ny�� �� ,�' ��
� Certified copy is here fornished. /
� FOR APPLICANT TO FILL IN(PRINT OR TYPE� DDR 55 rY'�"1/� PJ
Cer�ified copy is filed r u n s
li depa fm nt. NUMBER FIxTURE OR ITEM � FEE ��AIiTY �y
r � WAiERCIOSET /{� J`"4�O �
Dare+C�Applicanr � vtJ NEARE57
CERTIFICATE OP EXEMP710N FROM WORKERS' Z BATH TUB O CR0.5S ST. t'YlGf'�I� Y
COMPENSATIONINSURANCE � OWNER
(Thi�wdion npd not b�tomplNfd if th�work Involv¢d 6y StiOwER
MAIL
fhe permit is for on�hundr�d dotlurs(5100)or lot�.) LAVATORV ADDRE55
1 cer�ify�hat in the performonce of ihe work fo�which this ��(,�
permit is issued,I shall no1 employ ony person in ony monner SINK CITY � � �0. TEL N0.96 '9'�7
so as lo become suble���o the Workers'Compensation Laws. DISHWASHER �
CONTRACTOR �
-.Dale Applicant CLOTHES WASHER ADDRE55 ♦
f"'OTICE TO APPLICANT: If, ofter making this Certificate of � � h �
�RIp�iO�, you 9hould become sUbject io Ihe WOrkelS' SWIMMING POOL RECEMOR C TY �
�ompensat'ion provisions Of Ihe lobot Code,you mu5�forih- �qWN SPRINKLER SYS7EM � M ��j " ���'� �
with mmply w�th such provisions or ihis permi�Sholl be SI ENSE NO. � � +'7 ��� �.r
deemed/eVoked. WA1ER HEATER CLASS
LICENSED CONTRAC70RS DECLARATION oiSTRiG7 N aROCESSEo Bv
I hereby affirm ihal I am licensed unde�provisions of Chapter 9 GAS SYSTEM OUTIETS f� '(n�on G.
(commencing wi�h Secfion 7D00)of Division 3 of the Business OUTLEi50vER
and Professions Code,and my license is in full force and effed. S PER SVSTEM FINAL VALIDATION
� �/_ DATE �+^ J'%/� 0.�
License Number 3!308 3 �Ic,Closs� Q
y�/� (� _��/,,Q FINAI � U.
Contractar � ` �ateJ_JLV� BY �,�-s—K.' �,
❑ I om eaempt undar Sec �
V
8.8P.C.for rhis reason ' plan ch2Clt f8e :_"1 6 Z 8 A a�
Date: y
CLUMBING PfRM1T ISSUING FEE S „ � � o .5 Z
Signawre —"
TOTAI FEE ( ^ �7 e.5 0
Plan check oPPlicam - � , r =
SINGLE FAMILY - �� ����•-��
HOME OWNER-BUILDER DECLARATION .Nome O�,� J��H,l
' .reby affirm that I am exempt from ihe Controcror's License qddress
w for the following reason(SecHort70.31.5, Busineu tsnd
Professions Code): Ciry Tel.No.
❑ I,os owner of ihe properry,will do the work and the �
strucrure is nor intended or affered fo�sale (Section
7044,Business ond Professions Code).
CONSTRUC710N LENDING AGENCY �
I heroby ofii�m 7hot there is a conslruction lending agency for
the performanca of the wark for which rhis pe+mit is�ssued
(Sac.3097,Civ.C.).
ket+d8�m n7ptrn� .
te+dEr'sA�{die�s --- �
I certify fhot I have read this applicotion and sio�e fha�the �
above informotion is correcC I pgree to tomply with oli CauMy
ordinances and Sto�e laws regulaling Plumbing,ond hereby
autho ze represen�a�ives of this County io enter upan the
bo e-me 4� d pr ¢� or}(��e ction purposes. -
��(�!�yp SEE REVERSE FOR EXPLANATpRY IANGUAGE
Signoture of PermiPe�V�� _�f
_.... '�__ __
� � .r s..��a+w`��� �...
_ !�t �=� .. �a.._ . �� i���
-— ' r++r►.o..e+��i •ae .
�i V '1 � C �E, iNSPECr�7R'S SiGNA7URE 1A15PECTpR'S NOTfS � _ p�A��tER j3ljitD��'i� C ARA i lv'v
Y_�7 � ti
UNJ N L �:Y r` �`7..� <� I he bY rff rt th �I am �4pr�f o thc Con�c le',
�kc� CH J ` C���'�',(��. " Lc L w f th foll g �o o (S fa. 7071 5,
�Ga eFid _�-�- ' dusinresovdPofession C d ):Anynryorcau fy�yf,ch
GnS�C .,., , ... 4 i �ope rt�.po � t ol�er,�mprove,d mol's4
� ' � '- ''a repair any s}rLc{ure p or.fo`�h t��•�ar�.; arso re
FC+7 V AfEF,f-C,T _� ' • .-� � ��- �'4� qwres'the cpplla n}�1or such permit�o Flle o s%�ned 5fn�e
'F't�r�9 .,-�ixi�..�, f . ',��'�^��~�. , menrlh,afh. sf�censedp��rs��onrfo�haprovi.onsofthe
GFS IES' � ) I � �F � Con}roc}vr's Limnse Law(Chap�er 9(cammoncing u�'�h
—��y�-r�'���°-�— �, Seciion 7000)of Division 3 0(ihe Business ond Proies
uTwTY CC.n:onp . _�_ , . sions CodeJ ar�hat Fe s exempf there/rcm artd tfis basrs
�— �` �.��. w � '��'� ., .:. �� '�-'' ior fhe o♦leged examptlon. Any violaflon oi Seclion
�Flnn� � x�;(r nn ��.�nl � ' -' " ' - � , 7031.5 by any oppUcont lor o permit subjecfs the appli-
r—, ;`i � canf fo a civil penolfy oi nof more�han five hundred
� _ �'/ � , dollars(5500).:
INDU T��L - - � � ❑I,as owner of�he prapo�ty will do�he work,and
� :
�1�T - i���� �� - ' �� " tha strutlure is not intended or offered for sale.
������ � (Sec.7044,BuslnessondProfessionsCode� iheCo ' :�
�'� � � ��� �- ��- � -`- '' ' tor a Llcense Law does not opply to an ownar ol property
who buifds or(mproves fhereon, and who does such
��'�``�- �� � � -� ' � ' �. .. z work h)msel/provided ihat such improvements ore nat
.. � lntendad or of/ered for sale.lf,however,ihe building or
. ..-��\ --'� �mprovemenf ls sold witRln one year o/comp(etion,the
- ownerbuifder wiU have fhe 6urden of proWng�bof he did
' '- i not buifd or Improve for thopuapose of sale.J
:.i�... •_. ... . -'�'• �.
I am axemp!under3eq.
1 . 1'�' � .�).+y-i e.,. . ,;�'. .
8&P,C.for ihis'teason
� " � Date�—._
�:
Owner
�_�_____` 1`^cCTOR'S NOTES
-_------ — �