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5 - WORKERS'COMPENSATIONDECLARATION eaa�ireTinN Fr�q p�l�nnglN� P�t�M�T . . �
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-: �aswre;:.nc a csraficase ef�W�iken Campensahon[nsurorxe. _.,�E B17{REV.:.10/81) ..�:: _ .-',,-'_' '' ._� . ..._7 . . . . �. .. .. . .. .
_, c+r cernfc c ti�er La6�C.� �QlJNTY OF E8514T3GEtE5 BUILDINCs AMiD SAFETY ,
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e ..,. ❑ .Ceriified ceaK-�a he e4Y fv n shed_. . .:_:. .. .. . _ ... '
� -�� ��� ������ FDR APpLICANT TO fiC1 IN(PRINT pR'TYPE) �� DDRESS (5 � '
; -Cart i+edcopy�s f�Ted with rfie nt�--�i[d'ng.lnspec- . . . �' . . . .
• NUMBER ..PIXTURE OR ItEb1 . . .... (�.. . -FEE .`. ..
: . �.7icn dep8rtment_ .. _... ..t.=-- ;_ _ � LQG4LITY..-� _. � .: �-.. .. .. .......:._... .._ . ;
t . DateLrt�,2.,�AppliGa : . _ � WA7ERCLOSEf ._ �... . .
WEAREST
. ... .,..... __,.. ._._, . _._ ... ... . . .... . ... . £R95S 57,._,-_, -_ _ �
• --, - _ BATH it78... . -... r. . . .. ..... ... ....... ... ......... -... .
� _ CfRTIFICATE OF_EXEMPTION FROIJt WORKERS' - - - � � -
COMPENSATION INSURANCE ' OWNER �� ��-�
� (This setNon need�rof be eomple/ed ff the worlc invohed by SHOWER �1` . ,
ffie psrmH h for one Aundred dollars(5140)or 1e�s.) LAVATORV � ADDRESS
? I certify�hot in�he performance of the work for which�his .
€ permit is issued,1 shal�not amploy any person i��ony-martner SINK G7v TEt.NO.'�^�� �
so as to 6ecome subject to the Workers'Compensalion laws. 1 DISHWASHER
� CONTRACT
Dote App�icant - � CLOTHES WASHER ADD{tESS ��
_ �i10E TO APPLICANT: If, after making this Cenifimte of SWiMrtnuaGs'OO�RECEPioR
amp�ion, you should become subject to the Workers' QTY 7E�.N 'r' �
Compenwtion provision5 of fhe Labor Code,you musl iorih- �q�/,iN SPRINKLER SVS7EM
with camply wi�h s�ch provisions ar this permit sha11 be SiaTE UC.
deemed reroked. � ! WATER HEATER LICENSE NO. CV+SS �
� LICENSED CONTHACWRS DECLARATION --------- - � OiSiRi�i n10. ESSED BY
i t hereby affirm tha�i am ticensed under provisions of Chapter 9 ' �SYStEht � OUTtf75
! (commencing with SecHort 7000)of Divisivn�3 af�he Busi�ss WTIETSOVER �. � � �
` ond Professions Cade,and my iicrose is in full force and effed. � 5 PER SrSiEn4 fINAL� � �ys��' ypLIDATfON �
j /+��/_ DATE ly�I}.�I;A;. V .
License Numb �Lia CIas4�c�LdfL � -1 �� - � �'' �
FINAk�I '+ .. � .t (�
Contracror ate `� 8Y i i _ ��`"' y,�
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1 am exempt under Se �
8.8P.C.fo�this reason plan check fee M
. - Dote: p�UM91NG PERMIT ISSUING FEE E
, $ignoture �
TOTAL FEE 15 �
4
i SiNGLE PAMILY P�an check applimni
E HOME OWNfR-BULLDER DECLARATION Name . �
! - � lre6y affirm that I am ezempf from ihe Gonhaclor's License
_.w for Ihe foUowing reason(Section 7031.5, Business and Address �C 5'�3 A �
Profass�ons Code): Ciry Tel.No. , ,
j ❑ 1,as owne�of the property,will do the work and the #: •t • �5 .
� strudure is not intended or offered for wle(Sec>ion � . -
7044,Business and Professions Code). � ° � G 2•�Q
j CONSTRUCTION LENDING AGENCY • • � C Z O O c=-+
+ i hereby affirm ihai there is a consn�ttion lending agency#w �
j ihe performanre of iha work for which�his permit is issued . � 'Z� 5 w.8 3 .
ISec 3097,Civ.C.)- �
i
Lender's Name
E Lender's Address
� 1 certify iha�1 have read this application and state tfiat the �
j a6ove information isxorcecL I agree to eomply wilh all Coumy
ordinances and State laws reguloting Plumbing,ond hereby
{ auth r"e representatives of this CouMy to enter upon the .
� o -mention r inspection purposes.
� p� SEE REVERSE FOR EXPLANATORY iANGUAGE
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