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0965A (5)
_ - . � WORKERS'COMPENSATION.DECI.ARATION � � . pyrP`��C�T/OIl1 FOR r ��lv6�IN�-rE�,u,�T -� - - �'-� i i hereb +F� .ti�r t have a i.,��a __ s � `i "76v,o6�6, -� � . - . . . _ �� ��sure o a ceihfirate of Workers Compensat on Ins ance, CF 3i7(REV.10/81j � - or a ca f�ed copy tFiereoi(5ec.3800,La� C) - -� � - - - ,�� � c�s��rv��€�s aru����s �t�c���r�G Ar�a sa��v .�� � -Policy No.�'�Company--a����..���_ .,., p . .flfi . - . .. K'� ^ � ,;." � (�� Certifizd copy is hereby furnished. �' � � y �fOR APPLICANT TO FlLL IN(PR1NT OR lYPE) BUIIDING a� P P Certified ropy is fiied with the counfy boilding insPec - �--- - �----- .-----��-- AGDRE55 7� ' �r�; � � tion�deparfineni. - NUMBER FIXTURE CJR ITEM (a FEE ;, f LOCALIiY ,� �' Cate �� ��_Applicant / WA,.P,CLCSE' . _._...._ 1 NEARES7 - . . % �r.� , , � �..,� ��--_ �:� ; _ _ a caoss s=. t ✓�e �y . CERilFiCA7E CF EXEMPTION FROlJ�W RK R5 i BAiH T1/8 �'' I��'" BB �� F . � COMPEh7SAiION INSURANCE � �� � � OWNER_� � � �',;4. SHOwER � 9 . (This section need rtot 6�eomgleted if the work-involved by - ,+t,Ait �;9� � - the permi4 es far aoe handred Eollnrs(SI00{ar lsss,� 5 LAVqTORY ,��} - ADDRFSS �� - �� � .� i ce�tify t4a1 in�ihe performance of the work fer which rh;s - � �'` � -permit is is's'uzd,I=ha(I.naf employ ony-person in any manner J SINK C(TY�� �� TEt.NO.��r�^.,s�g ty ,y =' ____ '_' B �a9y:�, so as to berome subjedio the Workers'Compensafion laws.- DISHWASHER � ''��II � � . - � : C - �ONIRACTOR ��q " ,,,� � Dcte��Applicani� ! CLOTHESwnSHER � —� r NOTICE TO APPLICANT 4f offe�makinp this Certificate of ADDRE55 �a�:� ���Bt,�� . ��Ezempt nn you snouid berome subject ?o the��Workers' SWbV�rtn�NG a00L RECEPiOR „ 'r,� CIN 7cL.NO.����.��,�� -�'-. � ��apensahon provisions of'he lohor Code,ycu musf for�h �qyyry gpRINKLER SYSTEM ����� �;� �" :�.mmply with suth provisions or ihis permit shali be STRif LiC '+j �����.�"` �t � deemed revoked, � WAT[R HEATER LI�ENS[NO. SS �:� �,� �; LICENJE�CONTRACTORS DECEARRTiON� DISi T NO. OCESSED BY . � _ �here6y affirm thot!am licensed under provisions o{Chapter 4 GAS SYSTEM OUTIETS � ---� +� € (commencing with 5ection 7000j ot Division 3 of ihe B�vness _ OURETSOYeR —�--- _ . +`� � qnd Frofessions Code,and my license is in f�ll fo�ce and effeci. 5 PER SYSTEM _ � `�" � ` �p J � �� � � .-� Q�a E� �`r�.��� �PALLD/tTi0�1 �� �-�- � iicense N�mbef��6�� Lic.-Class &%�b �,✓:,� }:.. . � FiNAt y��„�. �i.? �+ '�^;t �: . Cvntrac?or - Da�e ��a,� � � gY -'-"'" � �' ij- .,Begr1 ❑ � ' �. I am exempf�nder Sec. . . . s � � A �`� '�," - t:. � B.&Y.C.for this reason. - �— . �'�% P1an check fee 1 s c " r s � - Dare: ---_— z� � � PLU+lABfNG PERfNIT ISSUI'JG FEE S �� �0 - I ... : Signat�re�.� , �; - .. _—_... � � _ _ . .. „ `_ ,- �' ��' . . > . _ ?I OTAI FEE i ����. � - .. - - t� '�. i . � ` 1 - - � �� Plan check applicant .. SlNGLE FAN�ILY _ . -. �� � �''�'. ' HOME OWNER-BUILDER DECiARAiION -- Nome - � - _ - ' 1:,=;{ �- �-I hereby affirm that 1 am�x�mpt from+he Cu„nofror's!icencP _.��Address � ` - - � � ��� t �>for 1he ftillowing reason(Seciion 7037 5, Bus ness and '�'' 9'_: `�ssionsCode): , .. City � Tei.No. - � .`3°,�a �� -tJ� I,as owner of the property,will do ihe work and the �� - ` - � � � � "" ? � �� siructure is not intended or oftered for sale (Seci�on � � - � - - 3--�� 7044,$usiness and Professions Code). .. � . ��� - � � � �� �._ - �_ CONSTRUQION!ENDING AGENCY � - . � . s . I Fereby affirm thoi there is o construction lending oganry for - _ . - . ".� i . ihe performance of the work ior which this permit is issued � . . -?� -���j5ec.3097,Giv.C.l. . . y �- -tender's Name - � .. � . � . -� . �FJ� „: j--.---� Lender's Address' . �; 1 cerlify ihat I have read itiis appli�otion ond state thai the - . - � � �� ��. - -above�nferrnation is corrcct I ayre2 Sc comply wiih all Lounty � .�' � - � .- �- -_ '� ordinances vnd Staie lUws regulating Plumbing,and hereby . _. . . �,.�"A,.' j . a�th �e representa�ives of ihis County to enter �pon the -' - - _ -��' � -.a6o e n ntio d property f inspeUion purposes. � - . ,.' ` SEE REVERSE fOR EXPIANATORY LANGUAGE �� � ������ ` ; � . '< < . . - - u ,..� ' � Signa e.nt arrodtee � Oafe � = �- . - _ �_ - --�' � :.- ,. . '� ..-_.. -. _ .. :_:,.- _ . _. _, . . __ ,,.. '. . .',.-i� �..: .::.-. .. .... . _ .._ -., ._'.-_ _: �-�-_ =�=i_.. � . �__ -__.... . .. _. _. .. _s_ ._._.. _-.-::. __.. . ,:: _ . __ . . .. . .... _ ,. . .,Fr:.., F�� .w�... , , ._. . �, w ,. s ..�*-. 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