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HomeMy WebLinkAbout0964A (5) 3� - �� - WORKERS'COMPENSATION DFCIARATION � � �P��������� ��R P"�dJfV1BIN� PER�IT 6�S . ' - I nereby�afnrm-rnai i have a ceriir`imie ot conseni ro seii � 76A6G7A T - . �.R�_:: � insure,or p cerfificate of Workers'Compensation insurance, -� CE Fi7(REV.10'81)� � . � o�a certified copy thereof(Sec 3800,( h (.) ����;y{]p.CQ5 AP-!C'sEEES S!liL�1NCe APdQ SAPETY : �; � .��r�! �� . ; t � Policv N _. . �Comoa�v -. .. _ - : . a Certified copy is hereoy fumishe . - � BUIiDING � � � FOR A?PLICANT TO FILL IN�PRINT OR iYPEI_ _ qppRESS ,'1� / � _ �ertiiied copy is filed with the:ounty bo�lding inspec -- k' � .. �ion deparimeni. � NUMBER FIXTURE OR ITEM C fEE � �� � '�� LGCALITY �d���� Dafe qppp�p�� WFaTiRCiG5E7 i�" NEARE57 } �� CERTIPICATE OF EXEMPTION PROM O �CERS' �, BATh+tUe - ��,_,., CRO55 SL � r.r� - COMPfNSATiON INSURANCE f ---- �-"--- -�� OWNER � � �� " (This secfion nood not he complePed[f 7he work involved by . p SyowER �. Z , MAIL p � . fhe permit is for one hundred aloliwrs(5106)or less.) invqlORv � �� qppRE55��7 ' � :i F �- I certify that�ln ihe performance of the work ior which this � � permif is�ssued,I;hnit not employ any persorr�n any manner -. f 5!NK ._„r �.�- CITY �, TE.NO.���.+��jG9p ��y3 � so as to bamme subject to ihe Workers'Compensation Laws. . . ,n:�+'�.' y � DfSHWASHER �—� CONTRACTO � __�_� � .�x,�.-` y,� �Dale Aoplimnt CL6TH;5`NASHER '� ? �. NOTICE TO APPLICANT.If,.:a{} mak�ng�,this.C=rlificate of �. � ADDRF55 ���7���, ���. SIJiAA�VING POOL RECEPTOR ��-,y y ExernptronK"yo� shc�7d beccvne sub{eB to�iF.e Worke�s � 'c�ir ����.�'�1'7'&� 7eL.t�O.�rJ6-�7.vr,+� -"�� � � npensatian provisions of the Lnbor Code,you musi torin � � �� ; 9� com ! vdith such rovisioas or tfiis tAWNSPRINKIERSYSTFM _ C..�._,.-. . pY P Permit�shal) be : ____�. �_ . STATE uJ,sg LI p c_ s�_.�,� ��emed ravoked. � wr,TER H�ATFR y .t LiCEhSE NO.'§�r�'�7�"`►" aass 4 . . IiCENSED C'pNlRAC JXS DECrqRA?ION - ����- - '°—�- - �tsrR�C7 NO. �PR ESSeD BY "� ` . i hereby arf m lhnt 1 am I�censed� d r provis�ons of Cfiapier 9 � �AS Svj7EM '�OUTLETS �,,.-� ,- : S ' (camme xmg w�fn Seciron 7QOD)cf Divssioa 3 of the Susness OUTLCiS OVER —� -c�nd Prefessions Code,c.nd�my licen;e�s in full force and effect. �5 PER SYSiEM 4 i~ �F�NA� � r�����/�s �'�� �at� �/� `� �ALItl3ATiQN �� ; License Numher������_iic.Cl��ss��_ . � � �'�,� 5� �y: q,v � f INAi � - � �� Contractor '�" ,�Date -��d'd�° _ B'! .�,�., ' ^�.,� z .��. Q I am exempl un er Sec. � . n k*�� r +� � : � B.&P.C.for th9s reason 1 ' -�� a. . : Plan check fee �_� � � � + C � : Date: � " } PLUAflBING PERMIT ISSU9NG PEE.$ ��lY � � ! � Signqi�reLl� - � � � �� - � � � T07Ai�EE � � �� _ ,�d�P.p�'�PT � U PF i,� ��s � �--- _ � � �� - � Plc�n cfieck applicant � � . -. �_ - SING.f.PAhh11.Y � `' � - � HOME OWNER-BUILDER DECLARATIflN - Namc . - - � . � �` � �.�-. i hereby affirm;hat i am e.xernpl frorn the Caniractor's Lfcense-. - <. . . . . -��€�: q �_._. ' �..for ihe fvllov✓ing reason(Sectian 7037.5, Business and _ Address . � � � � ;; - �ssions Code): Ciry TeL No. - - ._„�� � 1,as owner of the property,will do the work ond the � � '�; � � . str�ct�rc is no?iniendad or offsred for sale {Sedion � � � � �, � } 70d4,$us nsss�nd Ptofessians Code). � . .� � . CONSTNUC710N IENDING AGENCY - � - �� .. i herc:by affirm thul•}iare.s a cons'�vcfon leeding c gency(�r � . � -. -� . ihe performance of the work for which this permit is issved � - -�_,���:. (Sec_3097,Civ.C.). - :�= � Le der's Name . - - ', -Lender's Address � � - - *s - ' I certify ihat I have read this applimiion ond stote�that the �� � � - "�..,; � above mformo`ion is cerrect I agree to comply wiih all Counfy .�.� _� � ordinances and S!ate laws reyufatirtg Plumbing,and hereby � . ,� � outhoriza representatives of rhis County to enier upon the , ; . , . � ab e- enf' ned property for irepection purposes. , - '"r SEE REVERSE POR£XPLANATORY LANGUAGE :� I _}_ ,�. 4��-���" � s.�•� . _ . s p , �,. }.i Slgn ,ure of Permiftee � Date � � .. .. .. . ,,�: ,�, _ , �, c� o�o �,a b o 'v'. ?� � A ��.. . � N�7i � � �O y i= q4 . L'Z 7 � ..� CS D � � � � � ... � . - . q O � '�' u�i Z r' 'n zi �z � �� O � � a A y ' � � rn � p� Ct} � � . /� . ��. � .. O � .. �� , . 'J � T A � . . . .. ' . � �� O S q � ' . � � ' .. (�,., �� Q 1 J Y .�. , ' �„ � .� m . . .. p . � . ., s O $ (� q 4 � C 1 � .�-1 �,- `� p � �� n �, :+ � �,� { .� 7d - . - � � `. A . �rt. 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