HomeMy WebLinkAbout1326A (7) �
ViORKERS'COMPENSATION DECLARATION �D�P�',���� {Z�,���,,,�� ,
I hereby offirrn the� I liwe q c�r7ific�N cf censant in self �yqgb�q
�a ■ �rs� p�
insure,or o ce�tificate of Warkers'Compensalion Insur�nce, CE a17(RcV.IOBI) �-�-
or c��c�[,fied coay ihveof(Sec.390(3,Lob.C.) Epidp;Y QF LQS/kNFiBbEB BFJ1W1N6 AND SAPETY
_ ,Ic�"�c�/�f'�'3 Company�,��- _
rg;.
u Certified mpy is here6y furnlshed.
� FpR APPLICANT TO FI��IN(PRINT OR TYFE) BUICDNdG
Certified copy is flled with the county building inspec- t+DD,P:55 3��c�.�-.-.� �.c��'w�,
��i����M� NUh18FR FIXTURi.OR ITEM. (e+ FEE
LOCALITY
Dsb hppli4drfi - �+MTEACL05€T �� -'�'Cst.✓ 4.(
CE�'TIFICATE OF F76FM9TION PROM VtbRiEEWS' B�4TH TU6 CRO:S 5i,
COMPE�vSATIOId INSUR�ANCE
RA
(FAi►s.e+ion�wd mrF 6s¢w�.l.d i►fM v.w#imeaM.d by SHow[R owNEa ..-x 7�:e..
fIF►pvTN i��tlT aA�/joif4H(�f00�M Itlf.I IAVATORY MAII
i certify ihpt in fhe pe(icrmance of ihe work for which this hODRESS .�F-�it �
permil is issuad,I shall net arnploy aay person in ony rtianner SWK � � Cliv TEL.NO.
sa es to became wbjecl to ihe Workers'Compensation Laws. DISHWASH[R
. � �S'(J CO�'VTRACTOR 6 ��/e. ��$��,J
Dote Applimnt CLO?HES WASHER AOOR£55
NOTICE TO APPLICRNT: If, afler making�his Certif�ica�e of ��'�7� � ��"t� �/r�
Exempiion, you should become subjecl ra Ihe Worke`s' SWiMMWGPOOIR€CEw70R /
' Compensoiion provisions of the Lcber Coda,you mus-forlh- �AWN SPRINKLER SVSIEM CRV p� � � �A` /� TEL.NO��/f�.�7
cE
wilh comply with su<h provisions or ti+is pe+'mit sholl 6e STPTE LIC.
deemed revoke�. WA�ER HEATER UCFNSF NO. . .�7 07 �q5$
LIC€3�SBfJ COatlTRhCTO�PS DGCLh4ATION D%ST,CT NO. ESSED 6Y
I hereF>y o{firm tFrei I om license�d�ndb pfov'isions of Choptef 9 Gb5 SYSTEM OUTlE75 �A
(commencinc�wlth Secrlon 70�0)of D�vision 3 of the Busme�s ounersoveR ��
and Professions Code,aed my license is in full force and e$acl. 5 PER SvS�EM FINAL
���� onTE �i r�r� VAIIDATiQM C
ticense Numb�-�� Lic Class � -�1 �.
.✓..rl��-l���` �� 17Y fINAI;c-,� r 4_`.-
C niroct-�� �"fh,re � �Y�j�'ti�'�� Lf--�'
❑ I am ex�rrtpf under Sec. E,
s.sr.c.fo��h�s�eason - p�pn check fee -"'
;Jr�ye� �i�� PWMBING PER751T ISSUING FEE S (1 � . ,
slgnarur z ,�y,, 1 ,.:���� r,
TOTAL FE€
Wqn check appllcant ,. � �� � � .
SINGIE FAh41LY
HOM€OWkEti-BURDER DECLARATION -Npme � ,�� s ��; �;(1
I hareby afflrm thol I am ezempt from the Controdo�'s Llcsnse ��Address
Law for fhe foliowing reuson ISaclion 703I.5, Business and � � � _. . ,. _
Professions Code): Gty TaJ.No.
❑ (' i.C � `[:[,
I,os owner of�he property,will do ihe work and the
s�ructure is not intendad ar offered for sale (Section �
7044,Burnws w+d Rofsceiorjs Cod�).
CO/r46�Ti�1fTIOM l€NBM16 ikC�6NCV
I hsceby o�firm thet rbwre is o<ons+ruNic:a landing o;qncy fcr
tha parfo�rrion<e of�hs work fw which ihis permit�is issued
(Ym..�,�c�..�i.).
' Ler�ehar's M1l�wis
� Lender's Address
� I certify thot I hove reod this applimrion ond sia!e that the �
above InForma�ien is cwrect.I og.ee ta comply with all County
ordinances ond Sto1e lows reg�lating Plumbing,and hereby
❑uthorize represeotatives of thi Coun<y to enter upon the
'�ove-m tloned operty for spection pu�p .
� SEE RE46RSE FOR 6XPLp#ATORY LkiN4UAOF
miNw D e
ItJSPECTC2'S N9Te5 O:^JfVER-�UlLDER DECLArtATIO:V
APPRC7VAl5 DATE IN5PKiOR'3 SifiidkTUIR
UNDEF:SLA6 WOR� I nereny affirm Ihc�t I�in a�mp�Fram Ihc C;nlrar}o�.c
ROUGHP�UMBING � License Law for th_ follo'�vin9 r.o;on (Secl:o,-r 70�7.5,
GAS FIP:NG ^ � - 6usinrss�nd Profe=sien,Cedaj:Any ci�y cr covnly whi..-}�
GAS VEV7 � � � � � require;c permif fo cons!ruc/,dse3r,ir�evw,,acvns„ish.
or repa,'r ony sfrucfvrc, prior ro ifs i nre, cLc r.-
HOT W,4TEit FiihTFR - ` quires fhe c�s{rlicsnl 1,^,r wch perrKil tu lile a si!v�ed stal�-
�P,uN,3�NG FlX7URi5 monf thai he i:li.�i�ed pursuant Po iiie provisiors o1 th=�
GASTES? � � ^ Confractor's Llcen,-e Law(CF�pier 9(cnmm�nUnc�with
Sectlon 7D6QJ of Divrsron 3 of Ifie 9usiness cnd Prc�es
UTILITY CO.IdOiIFlEC --- — sions Co.'1f)or thni Iw is exaw+p�+tfwreivom ar�the basis
ior the alleKed anernpllon. Rny violatior, 01 Secrron
FWAi i ���on ��n[ ----�—�—��---� 7031.5�y anY n,oPlicoAt far o permir sul;jec�s the ep�li..
canf to a civil pendty ef net reore �ken f7ve hunded
—_ doll�rs(5589).:
INGUSTfiAL ❑I,as owncr of th�prop�rry wll!da±he v:ork,und
WA57E APP�OVAL — � ihe 5+rucNre is nG inlxrJw�or oLfe��ed for s�l��.
- (See.7f4i,BwHne�s anal P}s�asoraws Ceds� if»C�rr+roc-
tor's Lleergr Caw db�no!applY fe or.o+mer ci pro}�erty
whe bdik�!vr inip►er�iMvean, c+ad wM does such
i—�— wark himsedf pravidwd ihat weir i�npeevenc�,h wc nof
interrrlscJ or offerad for sslr.H,hownvr,rf:e bu,ld,rx3 0�
-----�— irr.pro�w�sw�t/s srkF�wFi�iw w�e yse�r of ccn-irylei-ion,ti�e
awnr-6ai.�dw�wdN fhaw iMelwr'ebn of proving Ihci hr.did
—.—.�..�----�^.— not tiuild or tmpro-w/er tfre puepex af sc7e.)
i am c�sam�t Umds�Sec. —
B&P.C.for this roason _ �_____
�-----__—_ Pata_-------.-_._�__..—�.�---
-- Owner � ._
IN6P�t."TOR'3 NOTE3
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