HomeMy WebLinkAbout0792A "'°RKERS•`°'"°E"5"T'°"°E""R"T'°" �yy����,(\\//� ` qp ATION FOR PLUMBING PERMIT
I heieby,affirm Ihat 1 have a certificate of consent to self�`�10-0026 DCW 4i87 � c/-f�
76A667A '7 �
sure,or p cerliiicaie of Wo�keri Compensation Insurance,o a CE 817�REV.8/86) '��1 I I
[edified co ihereof Sec 3800,Lob.C. � " � � � ' � -- � - LI -
�P U � � CO •F 5 A�G � DEPT.OF.PUBLIC WORKS
Policy No. Campony , �. � � �
� Certified copy is here6y iurnished. . - UiLDiNG
r F R P A �,T�iQ iN`(PR1N� , vE) �
�� Certifiedcopyisfiledwilhthecountybuildinginspection - � - - . D�RESS O � e/t-jQ . �
deparfinenL . NUMBER � IX�1FE R�TEM1 N• •; �j h•"fE�!! . .
(�j /� �� OCAIITV
-DoIe�QQ_ApplicantC)IA�eN�Y'/�S�I� WATER C[OSET�TOILET) .� �� NEAREST � . . .
. �•; BATH TUB. � - � CRO55 5T.
' ��CERTIFICATE OF EXEMPTION FROM WORKERS' �
�' � ' COMPENSATION INSURANCE�� � ���� SHOWER � � � � OWNER l v� d � � . �
(Thlt s�ellon na�d nol bs complabd if Iha�work tnvoirad 6y MAI�
th�permiT I�for on�hundred dollan(5100)or lats.) � � LAVATORv - � G�' dd ADDRE55 el- �Q, �
I te�tify Ihat in the perfarmance of 1ha work for which this per- SiNK � - �
mit is issued,I shali not employ any person in ony monne�50 ' CITY .'TEt.NO. , .
os 10 become subjecf ro the Workers'Compensolion Laws. � DISHWASHER - �
' - � . . CONTRACTOR C
Do�e � - Appiicant ' '� - � CLOTHES WASHER qD�RE55 a L� t
� NOTICE TO APPLICANT:If,aFler moking fhis Certificate of Ex- Swu.nMING POOL RECEPTOR
emp�ion,you shoold become subjecl�a Ihe Workers'Compen- dTY � iEl.n70.(� 3-
wtion provisions of the Labor Code,you musf forthwilh comp- ' LqWN SPRINKLER SYSTEM - -
ly�wilh s�ch provisions or this petmit sholl be deemed revok- S7ATE LiC. J � O
ed. - ' " � ' � WATER HEATER ❑CENSE NO. ��ASS �p
� LICENSED CONTRACTORS DECLARATION DiSTR O. P ED BY
I hereby affirm Ihot I am licensed under provisions of Chop�er GAS Sv57EM - OUTLETS \- _^ -• ,
9(commencing with Section 7000)of Division 3 of the Business � OUTLETS OVER 1X�
fec,F�ofessions Code,and my license is in full force and ef- 5 PER SYST ' FINAL � VALIDATION � a
�h 1 G G �; DATE { l�l�`� o
license Nomber•�31�'7�I�Lic.Class�.��Yl � V �
�(� }� �� �� FINAL
Contraclo���.lr��Date�d `2Q - .. gy � O
� I am e�empt under Sec �, � . � W
a
B.BP.C.for�his reason Plpn CheGk{ee ► '^U 7�'�'�''� i
na ,�
. Daie:� . PLUMBING PERMIT ISSUING FEE S � fm �'0 , °,�
Signolure - � TOTAL FEE � t7 � � � ° •�1 1�^�
SINGLE FAMILY- �
� HOME OWNER-BUILDER DECIARATION Plan check applimm . � . � � . ., .;��(j j G?
I hereby affirm that I am exempt from Ihe Conlracfor's license Name. ' . .. . .�. �?�/,_��. .
Law for the following reason(Section 7031.5, Business and . . ..... � . ,
Professions Code): Address
� I,as owner of the properfy,will do the work and the City Tel.No. � - � ' ,
. structure is not intended or offered for sale(Section 7044, . .. . ,
Business ond Professions Code). � � � � - �' �� � ' � �
� CONSTRUCTION LENDING AGENCY � -- '- ' ► � � � � �
I hereby affirm�hat there is a construttion lending agency for . � . " '
the performance of the work for which this permii is issued - � � ' � - � � . .
(Set.3097,Civ.C.). . � . � ,
Lender's Nome � ` .
LenderS Address �
I terlify that I have read ihis opplicotion and state lhot 1he - �� '� , �-� ' � � -- .
above informa�ion is coneU.I agree to comply with oll Coun�y �
ordinances and State laws regoloting Plumbing,and hereby . � � � � � .. _. . . ..
au�horixe rep�esen�a�ivee of�his Couniy�o emer upon the � �
ob e-me ed pro ty r�nspection purposes. � . . . . . .
����,�r c�� /��_g� SEE REVERSE FOR EXPLANATORY LANGUAGE
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igno�ure of PermiNe . � .Doie � � � -
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