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HomeMy WebLinkAbout0898A (4) i.__....._._�___.... _._..._..�, _._ ,__.____.----__�____._ - - _ _ ��� ---�-__-._� �.._. � WORKERS'COMPENSATION DECiARASfON q��.��AT#.�N FOR p�L�UMB_1N�C�P-ERMIT � rI hereby afi�rm rhoi I hq�e o cenlflectn of mrBene io self �y��A - - fr�o.e,or a�mnmu�ot eri puon rmuwncn. �en�REv.�o�e�� � w 6 ce:nf�'Sd capy�hereaf�c.e sa C.1 GOUNT1f 8F•COS�AN�Et� BUILDING�ICND"SAfETY i folicy Na,,,,,.,,,,,..,,g�,f,pmpony . � Gb1+�[ad�mpy�s�he�6h5�et+A3biertl. — . hy , aGprtffied COpy ik fl�8d'Wilh th0 COVt�t�iY11�.�R3�OC' �R APPLICANT TO RLL IN fPRIN7 OR�YiE) �� ���� � l . rian dep0iMl4ax � RIUM9Ex Frxfl�REt]R REM Q FE! �t�� --�- - - - - oa�e spFlueam -- -- .. wartaG.oset N�� ti'+� - �a -- c�et�GO�rrWA��' `sRn+roe cRossat. � �N 66 �� <<�� (This t�Ctio�n�ii!Rb[Rbi#§i�P.blid7{��.-_fTc�il3aT��d�iY . . �R . .- . ; i6a��rmiflrAora�i*Fvnil�l.dal(att.(S]p0�n.is:�. twrnt� oa oaFss �'�'�'� I cerrHy thor'rn rfim�S6d�th1[mu0� , ,.0 NQd�f� 40.�6i_- - - qc � Pe.mit is iaus�l:+rtrplDnronearpr .-� + r '�: cm �..r m.*io. ��k Ir.?J k w as rc coma.eb 'a�ka o6nwast�c cawrcacrort , ,��� Dma PF e ' � u07�wh�FR A�t �.-.. uo to �Sa �• _ � �J� Nc7ri tD _ �c,�vT. �� �,nr.r�k �h�dir� ta o� swu,uurnro+�aECEv►oR Ex6�+WW�+, ��hou�8�b4i.ame� arh aor �6y. �7iQn c� '�` m.r% � i; Eomp�tmap6lfpTc+rtSiCns:of!)ICtdblB '-- �KQ1I��XfptiM IaWMSPRIMUFR�SYS[EM _ . y�nh apmPly wifh �veM�,meiaiopS or If�QaCbIU ahqtl�be SiA uC: . dlO�ld�OvQkQSJ. WA7ER�NFATLR ����. �� u[ENSE4 CONtttACR3R�i P�aS9RAt1QN, asru�cr rro. Eo ev � I ha.abY aHinn�twt tmm n �4cP�t�i�S��aDtar Q .GaS srs�6H � (wmmsrMnp�+�Rb SICUIfl1t�Ob�e1#�$'OV'�lt�y3tp�r �� 0�•� ondProfenivmt�rst�andernrakA�V���iJU+t4ledactndatfen. 'stfR�� p� � VAqDAT10N °' DA�E V ' � kice1xe Numbgi - �%c.Clms.,,,`..�,__ F� � pContrattar — - ._ ...DCR1�--. . BY V p !J �om exemp�undap t�E. d p N a 8.8�.C.for thu.eason Pl�n ch�Gk f�g �:, � Z I . 1?ar0: .�-- PWMRING�NMIT tSSl1�NGfEE S ["' �� i. SignaM --- ,iOTAI FEE :`�j` J � ' p� �vtnn eheck appRmnr � ° HqME QIMVER-8tt14DEFC(�ECUIW�i�OR Nome � - - ����5 � � 1 hereby Pfliem M�uti om exempt hom wh�mvos+or.kue�oe �C�9.E F {,ow ior rhe following repean{Se�on S,$vaine�ond Addresn � � �, 9rofes3ians Codti�: Cify Tel.IVo. ; # • • •,• •5 6 ❑ 6,on owner of�he prnperry,w�IV do+hn�,kprk qnd*e I a"•� �5 Q � �true�me is nof intended w oHar{�d for tole(Sernon . � � iWa.8oa�nnss arai 07ofeaatans�nd+�• • = e.1 Ea 5 0 u �NStRUCf�N�tENSiWO RS'xF.NC� � I herohy aff��m�harrhero isR<pnittrys[i4A<ending qgnoey for 0 Q G� "'E$ � �he POtformqnce Ci Ihe a21Srk i0e wKitk�dVs Pq[ldif iz i�cuad ' (sec.707),trv.c.k ( Lender.Nams . _ ... .. .-_ ' . . 4 p te��dels�d�esa i camfy rtwr�ho.arood���s ap4ireprri�oncl=�q�e xfujr eha � � abovs intmm�Mn M�cavqeR Fo0 . �1pIX�NItG�dt�gunty . l F�Cncea CMI Slptb�Y qo ��.'Pf�y'1hMQ�ae�d F1iE7'!}1Y k cu orize sprp e -dE 1#�� . tD EHt3r v�pon�he � C ab s mt , �r _ .�o+da • _ S��R�YERS�FDR EXP�ANAtCfkY I.ANGSIAGE �, Signaiuro of Ve�mitteys �K� � �- �� Y � - - -- - - -- - . ._ _ �-_____---. �- - - _..--.._ ,_ � � i avvaovAtS onre ws�crae�55roNa7uaE INSPEC70R'S NOTeS �OWNER-BUILDER OECIARATIVN 1 I � UNDER SLAB WpRK . , I hereby affirm rhot I om exempf from ihe Controctor's ' ROUGHPLUMBt�!G " Liconse Low for ifie followiny reason (SocNon 7031.5, i, � GAS PIPING � - 8us7ness and Professlons Code):Any clly or counly which �' � GAS VENT � requlres a permlt!o conshucl,aller,improvo,demohsh, I HOt WA7ER HEATER '" - or repoir any 5lructure, prlor lo lls Issuance, afso re� � qulrss t6e appficaM for sucF permiNo lile a sl�ned sfate- � PLUM371:G FIXTURfS � - � � msnh Ihaf hs is 11[ensed pvrsucnf}o fl�e pro�7slons oF Iho � 1 GASTE57 � . .. Confrocfor's llcense Law(Chopter 9(commencing wifb ' ' UTILITY CO.'NOT�FIEP Section 7000)of Divlslon 3 al!he Business and Pro/es- � � . . s�ons Code)o�1ha1 he Is¢xamp}tBere/rom ond fhe basis ; c�� Yor ihe alfegad exemplion. Any vlolollon o/Seclion FINAL -,��i[e�on yrnnl � � - 7031.5 by ony oppllcaM(or a permif subjecfs 1he appli- . . � .� canf to a cFvll penaf{y of nof more lhon flvo hund�ed dor/on(ssoo).: �'� INOUSTkIAL . - � � � � ' .�I,as owner of 7he property will�do ihe work,and � WAS7E nPPROVAI � � �the structure is nof intended or offered for sale. � (Soc.70M,Buslnass andProlesslons Code: iha Confrac• ' , � � .. . � � , Tor's Licenss(aw doea nol opply fo on owner o(property � � who bwfds or Improvss }hereon. ond wfio does such work hlmself pravldod thot such Improvomen�s orv no� 'I ; ' Inl�nd�do�oflxed/orsola.N,6owever,fhc bullding or ' � , ' . � . Improvsmmt Is so7d wlthln one yeor of compleNon,fhc ' � - � owner-6ulfd�rwlffhavatheburdanofprovingfhat6edid � no�6ulld or Improve for 1{�e purpose of sole.J i ' I am exempi under Sec. , B 8 P.C.for this reason i Date Owner INSPECTOR'S NOTES I i 4