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HomeMy WebLinkAbout0982A � �. -- VJORKERS'C.OMPENSATIONOECLARATION ApRLIC�T101V FOR PLllIUi�I�:IVG PER11111T � �.- .�3 �� � �� i hereby airirm tnai i nave a certiiicoie oi conseni �o seii`�� �bqbb�q - '- - ---- `--�-- - — - — _��:�: insure,or a certificate of WorKers'Compensption Ins��nncz,-:- �F fl171ftEV.10�811 � ° g"�� � or a cert�f ed copy thereof{Se� 380Q L b C)p � � �- -�' �,�l� {d C��iiTY Og LOS�,@�3SELE5 �f!!l�IPl�A!dD S EFY ' Pelicy No^P_��O Ccmoan .�, ...� _ .. � e � ✓l ��� ,s._ �. Cer if d copy .here6y fur ished�� - � - . _ _ FOR APPIICANT TO RLL IN(PRINT OR TYPE) _ gUILDING _�_ . . . /�� �Cerht�ed copy is filed with ihe county building mspec aooR"r5S �^�° . fiondeparimenf. -NUMBER FlXTUREORITEM C PEE ^ � � LOCALITY �� � Da1e��� Applicani / `,'�'+'���LOSEi I . -. NEAREST - .. � CERTIFICATE OF€XEMRTION fROM O .ERS' SATH TU6 _ � �y CROSS SL �` � COAAPENSATION INSURANCE -- � � I OWNER �n � SHOWER � ✓' ",�; ' �. (Thix saation need not ba compfMed iF fhe work invoived by MAIL � � fhe permi4 is ior one hundred dolfars(S100j o�less.} - iavniORv ('j .--,� ADDRE55�� .. � :'T'� --i cerfify thar in the performance of the-work for which ihis�� � pa�mit s issued,i snoll nat ernploy any perscr.in any mqnner` SINK � ^' CiTY � „p i TEL NO. �.�`��[yQ ,'*�: � .�.so os to 6ecome subject to iFe N/orkers'Compensaiion Laws.-. { . , , �`� D15HWASHFR ' �/ -`�§� � � { "'V � _ [ONTRACTOR lr - �]`� L �� . �D�te Applicont � C[OTNES\VASHER y""� j'�"� qppRE55 � � �� . ..NOTICF.TO APPLICANTi If,.nRer mr�king this Certificate r�f .- . , . � � � ' ;;`. `- S4viMMiNG r"'�i OL RECEPTOR j , ..Fvemption, you should-�become subj=d fo�.the Workers' - � ClTY - TEL r! �"�� ' �' ¢ �oensation prov"isions of ihe Labor Code,yo��inust fortl• �qWni SFRin�xtErz Sv57eM � � y ,u�: . , omply with such provisions or this permiP-shatl be STATE LIC. „�„ �? 4�deemed revoked. � WATER HEATER �- �.,� LICENSE NO. y� 55 ��� '� � � !!CENS[U CtlNTRACTORS UECLARdiTiON. �. ��IST&�C7 - .OCESSE�&v �_�� I iiere6y crKirm thaS I am licersed under provisions of Chap�er 9 �-� ��SYS1tM �'OUTLETS j .--� ..^ `} . �/1�s�._a��.,s_e.r '#�`. <:.r'v`" �r' (comme .ing wi!h Sertivn 7QQ0)of t�ivisian 3 of'he Bus ness OU1LEiS CV[H - -� � and Professiore Code and my license:s�in fo!!force and zffect. :-. .5 PER SYSTEN. � FINAL �*� � j��J ,/� , DATE l.- ��U�P�`EHOW .,� , .� � rS''—�� �..License Number�_���� Lic.Class � - ! --�=!--- , T�� �-�' �`� I �INAL �, ,�"� Coniractor �Daie ��'��� -���—� 8Y � �-$�" � - �,:. ..�.. � � ,"�d, I am exempt und r Sec � � `�zA�-. °�� �� � B.&P.C.for this reason � - ��`� Pfan check fee 1 >fl �; d . � � �- � - � � � � � �f�� PCUMBING FERM7T 1SSt1WCr FEE$ � � � . - 5"rgnat�tr� � '� , _ , r' .1 .t� . . . ipTA.L FEE � rp �. � '� " : . . ¢. ----------�---____- : . . . � Pian check applicani ' . . � � 5:k, � �:- ' . . � � SlNGLE FA,�AILY - ----- `•.. . <�.� � � HOME OVJN'eR-BUILDER DECL,`vRA710N �Name - �� ,� - I hereby affirm Maf I cm exempt from lFe Cor;r�etor'a Licanse � _�.Rddress � - � � n .for ihe foilowing reasan (Sedion 7037.5, Bustness and ;, - . _. � �. - ! '+�ssionsCode): � - . City TeI.No. . .�? tJ� I,t�s owner of lhe properfy,will do the work a�d ihe - ' . . �%� � ._ � trructure is not intended or offered for sale (Sactwn . . ��� 7444,Business ond Professions Code). - ;��, � . ' � . CONSTRIICTION LEt�DING AGENCY . . � - � � : --�' �, -�I hgre4>y afFirm ihot t?iere is o construc4ion lendnq ogenry fQr :- . � ' . the performonte of the work tor which this permit is issued � . . . . �s�. . �. {$et.3097,Civ.C)_ � � :k, . : -�Lender's Name � - ��� �� Lender's,Address � � - � � �� .� i ceriify ihnt I hn.ve read ihis appGmtion and�stafe that ihe '' - J � . -_�:� � above-nformoflon is correct.I ogree to comply with oll County � ���,` - - �. ord� ces and Siate laws regulating_Pl�mbing,and hereby,..� . �. - i a fho' rep esentalives of this County to en}er upon ihe.; ���-� � ope-r i nli�n d p�operty(or inspedion purposes. .. 1 L t ,+�—p SEE REVERSE FOR EXPLANATORY LANGUAGE j O �l � ,�/-a� �. � �_ Jignai�re�ofi Permittee � . 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