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 :�
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