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0963A (5)
- . �� „w.T_,., ... ��� �, - .�"�-�''c .z�'t ,.,.:; .�,n, ' .: � +.« ..:: �Y'a-, �'x ','' ,1 � a � p p.p E/�p� p, p p�p�� j��A( , ,z.� ..LL...... .M a ._ . ."':-` WflRkERS'COMPENSAflON OECIARAT�QM`;' � . .�� .....:F#����4/�4�l:Ll-iY=-��R����MQ�I!\7==:P�Ri1F!'4T _e�e_ .,: , 9 i� ��. ? ' -( h2retiy aiTlrm-fFlaf f hpVC-cI tetiii'icdfe-oY conSZtSt"10 se17"�-.���q��(i '�- -� -. -�_. __— _.. ._. ._._ - ' .�..-.-�nsare,-oe a certifkete ot Workers'Compersallon=lnsur�nce,�;�c'E 8�7(REV.=fOlBty-��>__-, � .�--a ,<- •,=�.v -.-�-.-..-�^, . ;.-.�• -_:=. , �=.� �.-,..�� u-�mtl,.�r�^�^. �r�-7 �: '' . or a certified topy thcreof(Sec 3800,Lab.C.) �.- � ����TY�F-LOS-!!?�ls�lGS- :_ �R������fNr-AM9 SAF�TY - - - '_'_ - � �j ,/ � . - - ,'��r - � - .Qr,licy N.."�if�__,���Y' C'._.n ,�o+�_�. ,. ; . . ... _ :� .. . -� ���h� �:.�_A"-� , m a � -� �Cert�fied copy is hereby furmshed� � � . � FOR AP?IICANT TO FILI IN(PRINT OR TYPE) (BUILDING t �� C�rtified copy is�iled with the county bu�iding mspet ---- - ADDRESS ,�a�`� .� �� tiondeportmeni. . NUMBER� P!XTUREORITEh1 - C PEE ����A��TY �,/�`sfJ � � -��i�L e ,� WH�=�n��E� ��. ��� � � a ��_.Date bpolicqnt - �_�,�: NFAREST ` CERTIFICATE OF EXEMP710N FROM-WORK 5' ,'� BATHTUB �j-> CROSS S7. � . s � . . COMPENSATION WSURANCE . � SHOWER �OwNEk��� � � - -�[Tkis section naed nat be completed i6 4he work Invoived by : - pnAit eD - The p��mit ia for ooe hundred dollars($100)or less.) E�.'' �qyqrpRy �O � �qpURESS �2 '< `�I certify that in the performance of ihe�.vork for which ihis � � � . �/f_ j� ` ���� e � � -'permit is issued,I shall nol e.mploy any person in cny manner ��NK ✓�r �^ Cil Y�(��� g�� TEL NO. � g .�_so as�o be<ortie subjeQ ro-ihe Workers'Compensation Laws. _ /' pI5HWA5HFR � � � • { GONTRACTOR � � r ' -Date � .. Applicant . j CLOiHES WASHER � ----- ADCRE55 �'_ � :NOTICE:TO A?PL1G'aNT:J?, after making.r!�is�Cerfificate o4-_,.. SWIN�NWG POO�RECEPTOR - � -Exampi�on, you shou�d becon+e �cb,ec! to the -4Morkers" _ _ � �Ry ' TEL NO.(�� fa � �. �ensation provisions of the Labor Cede, you must for�h �py�N SNRw!:LeR SYSTEM d � � "'-'�' �comply-with wth provisions or ih�s permif shall be - 1 STATE IC. �p �, --- ucErvsE rvo.���(v�� aA s 9.. c� s.> � 'deemed revoKed � . � WATER HEATER �� �^� � � ' . !IC€t�iSED tONTRACTORS fJECCAR,4TION�_. � �-- — � � �/—� �� . D�S7., NO. ? ESSE�8Y - � � ��I herehy affirm il�at I am licensed under prowsions oiLhapter 9 aS SYS?EM �OUtLElS �ip-- � � -, ,-lcommenang with Section�7(YJQ)of.Division 3 of the B�smess. r � CU7L[TS OV[F j E � �� — ''��°--�--.--- �"'�'`'��Y�"'�'�� ^�': < -�and PrafeSsions Gade,and my license is��in fuil force and effect 5 PER SYSTEM F4NAl �7 f}���jj,'#"���ij r�? s� r_ ���� � ` � .License Num6er���r'"� L"+c.Ciass ��� � � ------ �i SG ` DAi£ . . . . � a: � ; . • s� y� FINAL �';-: �. .. �Contracror� � Date �'#A'� . . �� gY . _ ,�9 ,�. ❑ ! V .�f � -� 1 am exempt un�er Sec. f . . - -y�.f � 1 ' ��� � B.&P.C.for this reoson a � Ptan check fee � �r ���`; � Date: . -- ;;,� c-j� zu f � y PLUMBING FERMIT ISSUIN6 FEE$ �- �� � � i ,�;. � �Sigr�tu;ep . . . ;, � - , 7QTA!FEE ��'�G - � �,. � I�. # �- Plan check applucnt ��-- --- ?!� �( `'�'�� SiNGLf FAh51LY -. �l--i--y--^.—.._ ---V . . HOME OWN"cR-BUILDER DECLARAi ION - � Name � . � _ ��^.. y - I hereby affirm!hat I am exempt from the Conirador's L�cense � p��ress � � �- � L °or ihe£oilowing reason(Sectian 7031.5, Bustness and _ - . � � f ' =sions Code� ' � � �; )� - City Tei.No_ . - .�4 � y� I,os owner of 1he proper?y,wiN do the work and the � � � � �v�` structure is no'iniended ar offered for snle (Seciron . - � -- �: a �� .7044,Business ond Professions Code). . ��, - -. � � t. '_ -- CONS?RUCTION LEN�ING AGENCY . . � -� ��i her�by nffirm tfiai±here:s a mns'.ructian lending ogency for�� � � - � � - _ - �-�� , ihe performance of the work for whlch this permii is issued � - � � � - � ' '�`��� i -; ISec.3047,Civ.C.). . � - .;�; � .: 'Lender's Name � —.J.- . . . , _ � �;. p � �.ender'sAddress . . .�'�' f -. 1 certify ihat I have read this application and sf�te ihnt ihe - -;�,_ - - �. � : ��above informalion is correci.!agree to mmply wi}h all County. ��� - . . _ � � ordinances and State�aws regulaGny Plumhing,and hereby �.��W' � `- ���auihorize representatives of this County?o en�er upon ihe . _ - . '.��, e-me ioned propert {or inspection purposes. � . _,�,� I SEE REVERSE FAR EXPtANATORY LANGUAGE � � � , �'9 pfd � � . Sig at�re-of Permlttee Date _ , _"a�; ( - . . . ... . _ . 'S�P � G 1 � � 3 � �, � .,.�� �G-+�� G �° U' � {'"' ��`+ `�- b p y �" \?'o � - � y �, �P'�i�'�C.�m -6 5 �. 'Zy e i y� i-G ��� � � � �,y���t��. ..,.....��-' ✓l � . 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