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HomeMy WebLinkAbout1412A --- - ._..___ . ._ ._----_-_ _._.,..______.._._._m....---��.. �_..._.__ _.e._ -- --. _. . ..._ __._. _______...._.,.____.�. _ _. _,.__--.__ . . � ry WORKERSCOMPENSATION�OEGLARATIQN � APP�LI+CAT�I�'JIV:fO.R�P��.MBING PERMIT � f I her�affirm�Yqt F hnve o cenNimt!of cansient Ip cpli 7apap?q . - I�aur or o ceniflcyta ot�wbrkerY Cnmpensatbn Iw�manm, CE g}i(REft.�o�ek) or a ce.�ifmd mpy ehmeof(Sec.�$CO k�b.C.) CCUI$LYO�'LQSJING�I,�S BUIL�ING ANDSAFE�.+ y . � Q�No. CampnnY . . . _ . . -_� - - - .- . _� --- "^"(. CernAed eop�r�s hsrndr tumMhad+ FdRAPv�uiar+z m r�u nu�vRuvr�cmoEl �� ❑ �S � CanH�ed�ovY is Hi6d wirM tWe couru9 baltdin4.in�pec- , f�at+� � � u �im�deqanr�nr. � tocumr � Da�e..,.--�,...�MR��sonc ... . . . . wwRRc�aS.E► - /� f` � CERT1Flf.ASEpFEX�MRftON�ERDFA�VJQRKERS' 9Ant7tlB �b7. LT- . ° f27AM1PEN$ATION INSUICRNCE SHOWER ��. (This#�e�[on ps��d�nof:b�tompf�i�dlf i,-�v otk invely�d 6y � i �B�p�rmietc:isr eni Fumfhd Ao1Can:{F�Qol+srieu.f uvwmRr aocarss j 1 eenMy ehot in tAa pDrfqrew�pncb 6f�N6 worlc fpr which thia . , - - . . I�, permi�is Wupd.I�►t4flY rnn�mpl4y onY p6non in cny mGnner srtaK c�Tv �.nip. • w as w became a�teci��e�ha atkerY'Compenaaeor�ows. /�+ I �oI5MwA5HER coNTRACTOR � G4 1��� � C� � `' Dote C�.�npplrcan -� cion+fs wasr+ea �� NOTI� 1O ISPPIfClWT:i#, ditbr�� � � - is�C9rilfimte of � - � � . -. -�. � Eaemptio�, yoa �huuld� hewirte aib�'!u �a�the-Workers' sw�MnniN3���rars ctTM �� Compenwtfon Prorl�imn af tdr tdbo.Cade,W�muat fonh- tnwW�S�pNKIFR SrSTEM �•�� � wi�l�eomP�Y ��ti ���h ptev.isipni ot O+�s D��ir shall ba srAh u[. t I deemed ro�roBed- wamt�ntnt � u[i�wa. ` j cwss C'.r ✓ . IICEN$Ep CQNTRlICi[�RS DEG3ARl4TIDN -DISiR�[T NO, av �' I hero6r aUien�hp4 F9J�heeroad.�er prewisioRt•44Uwptar 9 CAS 6�57EM OUttE13 � . �u (mmmeewr��wtlt+6anron 7Q00)ot Ow�slqn 3 of 1he B�siness �rs�R ond P.efeukf��Codm and eh�iroo;e b m fulrta�n�ondaffec�. a aE��bYSIFM. � �+ �� VA ATION p I'�� kice�e Numb r �5�- � � .CI^��`—�� U F' ��� � �FIIVPIJ, O � Contractor _ � Cate - ' ��sV - F . � I em e:empi undn Sec. � � 6.8P.C.for Ih:i rauson y Plon chHrlc fea z o��°: vurnnaiNc�v�,T issuiMo�: p ► sipnorurcr— ' '� Tora� �1 4.1.2 A � Plan chxk appiimnt � SINGIE fAMllY . #. i. . .rj �� HGMfIE OWNER$UIWE&�DECLARATION Name - � � . , . �_ I herl6y afftrm tha�I om exqmpt!mm thp Conllnclbr's kicenee ���� � • •2 2,J�� . �. Low for the following recson(Seerioai�031.5,Buairress and � J� �r°f0ui°^�Codd): Ciqr . Tel.No. • • •2 2 5 0� I'. ❑ I,at owner af the p�openy,will do the-wark ard rhe � � � D�.� 8�a 5 � �tructure is nol imended ar offAred fw wle(Section . . � �' 7014,Business and professiona Code). . . � I. CON57RUCTION IENDWG AGPVCY - - - {� I hereby�rm Ont ihera itp m�SVuctian bnd'ie�OgO�xy tor . { fhe perfarmarrce a1�e wark fm wl+ich thfe perMii�is.as�ed i (Sec.309T,Civ.G.). � �1 lender i Nnme - � , ylender�qQBresa � . � I esrr�fy�h�I Rara reod�kis aPPlieotion and��le�Bat rhe ► .� . , � above i�ormpnon ia maen.I agteO ro mmpiy With�00 Cmunty , . � ordinp���as df�d$fp18 FGwt rogu�dflhg V11t[l�hlt�,�Ml'hlTBkfy � . � oa�Fmr�ze�represenrati"ea af rhw Cewnyr ro eet4r apan ene ;d: e- � � oed W'averry iw inspectwn purpnses. . . 6EE REY�R3�EQR�Xl"IAt1ATQItY'IANCd1AG� � � "`�—���' ( Signoturo of a m tee pote - � � � � s_. . _ __ ._ _..__ _ _ _ . _ . . ... . _. _ _ --- _ — i ! ncPaovnis DAiF iNsaccrars s�cNnnrae �NSVECTOR'S NOTES OWNER-BUILDER DECLARATION ❑uDERStAe WORK I hereby affirm that I am exempt from ihe Contracfor's � ROUGHPLUMDING License Low for the followine� rcason (Secfion 703�.5, GAS PIPING � � 8uslness and Pra(essfons Codel:Any cify or county which �� GAS VEN7 reqWres o permi>ro consfruct aller,Imp�ove,denrolisf�, �� HOT WATER HEATER or repolr any sfrucWre, prior fo its Issoonce, also re- , - � qWres Ihe appficonf for wch permlt fo lile o sfgneds�o7e- '�, PLUMBING FIXTUREs � ment 1ha�ha Is Iicensod pursuan!lo Ihe provis;ons o£Ihc � GAS TE57 Conlrador's llcsnsc Law(Chopter 9(mmmenNng wi}h - UTILITY CO.NOTIfIED ' Settlon 7000f of Divlslon 3 oi the Buslnass and Froles- �� slona Code)or fhcf he is exempt there(rom and�he bvsis � 1or tha oUeg�d exemp0on. Any vfolafion oi Secfion �i FlNAL �' � . 703L5 6 an o licant for a erml�sub'ech fhe❑ ft- n�cr on ronf Y Y PP P I PP toM fo a tivll penally o/not more Ihan live hundred douor,�ssao�.: INDUSTRIhL � 4YASTE APPRO'✓at � ihe str❑uctura Is noi ntendedror o((e ed fo�soleW�rk,and � (Sac.70M,Buslness and Professions Code: The Contrao � - , tor's Llcensa!aw do�s not opply fo on owncr of properfy . who bv7lds or Improves thoreon, end who does such � . �� work hfmseH provlded ihat soch fmprovemeNs are no� � � ' !n}end�d or olfered for sa/e.!(,howeveq fhe 6Wlding o� � Impravemanl Is sofd wifhfn one year oi complelion,�he � owner6utlderwlll Fave fhe 6urden of proving iha�he d�d � � �. .-- � nof bulld or Improve 1or the purpose o/safe.) ' . � I am exempt�nder Sec. , '� � � � B&P.C.{or this reason Date Owner INSPECTOR'S NOTES \,