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-- 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
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