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0976A (5)
4�.� �...��*,,.�` 'r ,:._ _.._.- i� ,�,,�1' � ,�y"�`� � ��/ .�- � w� E-..< �. �.. . .; � .�T .. ;. .�' �. WURKERS COMPEhLSATION�UECIAR£4TiOtV � a�:. �� �`l1���LP�1-�7�Q1�.LO����l1FlB�\����l�I-L. -. x �,. '� h kereby aif rm ihaf 1 hdv�'�a cer�Rftcote-_of ca senf:to lh �;76AG67A, _�' `s� �. ���� irtstrre;-or mcwkl`"rcate of W�rkera'Campensaporc-kns�rance gt7=k�V'70 St � � �� Y ��' ��� i f .�;m � s ;;. `y -,�. a{"� � ora.cer t¢ecF�aFythe e�{5er380;1„-I. b �) ��" � s� ��'�jj�fi�����S-�N�"aELEs�- "� -B�lf€{3�►.�'"s"A�I�FD'SAPE�Y �' �a�`�,�'s:.�a�� ��-� ���:^,--��..��r ,Y � w ,�--:: . �� _ � �,,.�1:g�, ��.�` .,.: ; �_� Ceir�f�ed�cupy is-hereby�furnishe ; � �� �'�'- `�'�`- � � ,�*'�."�*' " , -�� �gg �� � � ' t � �� fOR APPI CANT TO FlLt IN(P41NT OR TYPEI - BUILDING� /I-� �� ,g.�j.� g -. �CertrHedFcopytsfale�w;ththeT-cour+fy,�bwl3tM�}:inspec ------- ADCRESS � . . � , . � -,� ._ _.,_:f[on depariment �.` �- NUMBER�� -RXTUREOR-Ite`M - � � FEE � � ¢ _ ..,,...-�-� _ __..__ _ - �u:- - � � .LOCAtITY ���� R � �'; � �f��� ��. �- � ��- �----__--�- �� Dafie ' A Tcdnt - wAl'ERCtOSET - Pp . ' ' - NEAREST ' =�. _�,�� ,. � � � �RO55 SL ���- : , �-�- - LE�iFICATE'QFFXENii�TION KI�OM��WORK RS' �- �BATHTUB � J� �� - �•F �_.-__, - f'OMAENSATl6�lNSURANCE = _..,�.'.:i /- , -; .,;:�� �- `-� ,..D�VIVER � . .. - - f _ SIIOWER ._ ___ T� :.� -_ _./`� _;. �..�/��- � � 't...-: ? (This saeTfon�aed naf 6e eumpl�ted if 4he work invoived by �-� � MAIL. .�/. �,�'° � :` �the peemi8 is ior ane fiundred dolfan($100}or less.) � tnVnipev � qDDRE55 {� ' - � , .�I certify tn�t-in the performance-of Ihe work fvr which th s - - permit is issued,I shal)not empiny any person in any manner 51NK � �- �CIiV 7EL O����p� 'so-as to become subject to ihe Workers'Compensation Laws. oiSF�WnS�teR ✓! I _ � ,'CONTRACTOR - f � � Date �ApDlicant � � � �: d C�O'4FS WASHER , --�' ����--� ��� � - ADDRESS .��� � -. .�NOiiCf 1C�APFLlCR,lT�. If, ca£te marci�G th-s Certific�re of '.�. --�-- . _� __ �� �'�7LL�Q.� Y � - fxempt�n, you should became s biect to�the WorkP�' SWiPAMINGFOOLRECEPTOR • . ___.__ ..__ � •.-npensation provisions of the Louor Code,you must farth -C�7Y� iE1-NO.q�`�,�f ; �t�WN SPRSNKtER SYSiEM � ih comply wifh sucF provisions or 'his permif sholl be S7ATE �/ L�G � a . ,=�,��: � deemed.wvoked. - � WATE�HEATEI2 ! , !ICENSENO. 1���� C�ASS w��� � � _ ��LICeN5E4 C�N7RAGTORS DfG!ARRTtON� - ��� — &y [�tSTRt MO. . `PROCfS�FD BY ?"' . GASSYSTFM OUTLEIS � I hereby affir�m th�t I om licensed�nder peovisians of Chaoter 9 - � � � '° - � .- �.{commenc.2g wiih SecYiun 7R�0)of 6ivision 3 of ihe 8�+sinees OUi�F50VER � ��'��r��r�� ��_j�_ �.-and Professiens�Code;and my license is�in tuii force and e`f=_U 5 Pe�SYS;Ehh "�5 ,{ ,q�� ---i-�- ��=wAL������ v,�c�o�►�Eor� ;���, � �-.l.icense Number_�✓ Lic Class�� � .�— __' DATE ����. fp F!NAL �$,�� � . y �r$ � �'�e7� — -- 8Y . .. ���Contractor �"^"� [ iloie { ¢�' �,� ❑ tx.: . I om exempi va r Sec.� ��� � B.&P.C.Por this reoson�_::— p�p��heck fee ^ 7 - A�;� � � -- _._._...__�Uore:. PLUMBING FER(JdT ISSU{NG FEF$ �° ` ...� '-�•, -.. :Signaiur�----' -- ----- � � � - �'��. ,„,` ' "`'�' {i � � - TOTAi FEE aG' ' :� 7 �- - - Plan check applicanl - ��:�'`� ' ,'� � ' . 51NGiE FANiiLY � - . ��-� j _ -� � HOME OWNER-8111LDER DECLRRATION �� iVame �� ^ � . ;� � I here6y affirm that I am exempt frem ihe Coniracto%s ticense � � . . f� � :- - �v for the fotiowing reason (Section 7031.5, Business and � Addre.s � � � � e� � = fesslor,s Code): - - �ity Tel.No. � - �tr..� _ . � .. - - . 1,�s owner of ihe property,wi�l do Ihe work and Ihe _. ���. j shucrure is not intended or offered`or sale (Section . �� � - � 7 �� 7044,Business and Proressions Code). � - � - � `'`� CONSTRUC710N LENDiNG AG€NCY � � -- - � i_ . . . . .. . . . �` ' � I hareby uftirm thoi there u u-mnstrucrion lending aye�z,y{e� - � . . � _ the performance o4 the work for which!h�s permit is issued. _ � . - � p . (Sec 3097,Civ.C.). � - '� � ,1�. ! �� �- i.ender's Name_— � . �- � � - -.tender's Address - - - - � �-- � � t certify that I hove�ead thls appfica�ion-ond state that ihe , - � ' �� above information is carretl.I agree to comply wi�h all County ` - � � �-�- '-�-ordinances and State laws regulating Plwnbing,ond hereby � ��� . - � �` �(-::� _ au� orize representatives of this County ta enter uoor ihe,` � � , � `..�.�:� � o mei oned properry f r�nspection purposes. S�E REVERSE POR EXPLANRTORY LANGUAGE � ' + -.�-�' � r�-�"'�'� - . . � � � _ Si ature of Permitle-----l��� �ate � . - #. . , . .. . ;�, # ': \ . �� Q v - � n, G O c➢/> �y C,e A _.,�-�" - -n ' �, "> S� m =e��� 'N' �o ...._..,_ 2 ;. J+ a' ` s 2 r' ➢ �' . . �Q T. 'C � ..- qR' i G1 7i �c O . N� n ��.q. , � r�' y � � 2 "``� . . � . -o��o �o c GT � A "� m � 0 ,�� N T .�v--.l�` �\ O ` _ , �Yy 2 � • `��m , R 1 ,� 1 �`9�; c 1 � � '� � h `',m a '�1 `� ���a "�- N ` , � � � � - 4` � ``�`.� ��j��� � . . ' . � -= �. .. 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