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HomeMy WebLinkAbout0983A _ _ _____ __._. _ __ -- . _ . �._. __ ,...._ ,.., .,..._,_. .. . _ �: .. .-.- W6R�EERSCOMPENSATION-DECLARATkQN. . .. � ....-. A���`1�.�1 IO� F�JR��6���IIY�-�E-�IV,I I � � - ����: I�ttereby ai'IirrR�iltoi i tFaVe O cert�ticate oT consellt.to seiT �� ��p��q �� �- ' �'. . - . � - � insu�e,or a csriificate of Workers'Compensatior.lnsu ance,��- CE 817(REV.tOL91)� � � � - � - ��.� i or a ce�r fie cgoppy�rh/eseof(Sec seoo,�a .C) �0�1y7V�P L���;!�l��!ES �m�!�Q!ld�Ps.O�JD S E�ETY � • oolicy No��t�7l.�f�m ' d�� �,._ � � P. , e e �_ ��q - � ` f �_ .�_ �_-- . _ , . .. . . .. . . � . �, � � Certified copy is hereby f�rnished.� -� � - � �- � ,q �J ; - - . . - . . .. -. ..�- ` � -FORAPPLICAMTOFILLIN;PRINTORTYPE) � A��RESS�. �a�L- . �� -�Ly`4-P �� Certified cop�y is filed with thr.muniy building inspec tion deparimenf. NUMBER FIXTURE OR 1TEM � C FEE € � ��,,. � ,(p �' � � � LOCAiITY ,'{' � .��/_ L%� . JlA.7ER CiGSt� � � � '^�'�, �� Date �'" Applicanf ' � NEARE57 � C€RTIFlCATf OF EKEMPTiON FROM V fR5' � �BaTH ius CROSS 9T. a�,7 ��? COMPENSA7ION INSURANCE -- �� � '�.�' SHOWER �� � �OWNER �' .�, -(7his secfion need naY be eompleted�f the work Involved by �� ���� �/ -y:� the permti is ior one-hundred doilnrs($1�0}er less.) - i tnvnroRv ,� �.---� qbDREsS J �;� � . 1 certity ihot io ihe pqrformance ot the work for which this - � - i- '�`= = permil is issuad,i shall noi employ any person in any manner SINK ,..� �y P-- j CI4Y �� tEL.NO. �� { so_as to become subjeci io the Workers'Compensotion Laws.�.._ --- . . �� 0 OISHWASHER� � , � CON'RACTOR ` Dafe Appiicqnt �CLOFHES WASHER �r � �..�� � �° » 9� '� �ADORF55 f� 9 � 5- .NC3?tCE Tp APpLlCANT:.If,-flf�er makir 1}iis Carti#�cate et : � `���'s.�'-^ ,� � .mpiion, you should hecnme su6�ect to ihe WorKers' : I,SVJVv1MING POOL RECEPTOR r— -- p. T � y�` CITY fL.NO. �pe�saiion previsions of ihe�abor Code,you musr forth yrL! ��� IAWN SPRiNKLER SVS7EM � �� :com�ly v�ifh wch provision, or ihis perm�t-shall be-� �___ � STATf iiC. ����/' `� � deemed reJoked. � -- ( LICENSE NO. '� CLA55 fm ''s�' } � � WATER HEATER �.I �� ". . ti£-€'�15EiJ CONTRACTORS�JEftARRT76N. . - �— —- � -�— — --�-�—� --�-� DiSTRICTI�tO- P O.^.ESSE�BY '�; � � �- (hereby a$vm ihat I am i¢ensed wd� provisions of Chapter 4 � � VAS 5"S7EA4 �OUT+eTS � � (commenang wdh-Section 7Q30)of D vis�on 3 of�the Business �_ I,TLF75�V€R ^ �— ?-�.-._�.�,�..✓ � . � ����nd Professions Code,hnd my licens - . � , . s in ful3 force and effeci -'_—_- 5 PF4 S�`Si� --- - — � pINAL � . = iTAt�DATII�N � ' �� .DATE �'�^�< ? � Li<ense Number � � � -Lic.Class s'�� i . ���� � -�>t�'� . . . J , _ ,3'"���� � FINAi �R-'�:� �. �_ � - Conlractor ° � Date � I � BY f�,x^".. �g,�' �� � ��-_❑ I am exempt�nde Sec._�_____ —� --�t— � � � - sqsf - R.t4P.C.for fhis reasnn � —� - � �- �' �` `Plan check fee �; �CSa�e: ----—_ r__ m _ , g � � PLUMBIN6 PERMR i55EJ1NG FEE$ ( � - ��� �' � �= �"§�; .. � Signatvrd� . - �- . .,J .. . TQTR!FEE ��Tp.'+ g> �. � .. . , '; -. Plan cfieck appfimnt � .. �- �` s , - SiN3Lf PAMttY - � � � � � � HOME OWNER-8UIlDER�DE£tARAT10N � - Name � � � _.,. � '��? ;� 1 hereby cffirm that I cm exempt from ihe CoMractor's lice7se ':� ;,u�ress � � � � ���-r� F ' -;for the 4ollowir.g reason (Sachon 7037.5, Business and ,�. - � . ' `�;ssions Code?' - . City Tel.Na � . �. _ i � LJ 1,as owner of the property,.wi41 do rhe work and ihe - . -. . `�� j : st u ture is not mtended o�otfered fnr sale (Section . - .� - -�. � 7044,Susiness and ProFesvo�s Code) . � . � - S �- . . - . - :` 3 ��� �- CON57RUCTION CENDING AGENCY � � -. - - - . 3 I hereby afE.rm tMat 1-e�>i<_a construc?fon lend:�g aqency for � � - � , � . -tne performance ot ihe v✓nrk for which ihis permii is issued . . - ',��'� 3 � (Sec.3097,Civ.C). � � . - � . - Lendei s Name . . _ . �� �� L,nder's Address - � �� I certify ihaf-I have reod ihis application and slate ih�t the .. � � .- above infor�nation is mrrecl.I agree to comply with all County � ` - � 5� � � � ordinances and State laws regulaliny Plumbin�,ond hFrehy ,' - . �.��� � � � � ¢�': j aut' "e representatives of this County to enter upon ihe . � _ , . . y.� i .ov ienii d property f �inspection purposes. � �+p / SEE REVERSE POR EXPLANATQRY lANGUAGE � .� � -� � �^'1'�AA . . . 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