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HomeMy WebLinkAbout0792A (4) "'°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 camplabd if Iha�work tnvoired 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 Workerz'Compen- C�TY � 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 „a +� . 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�horize rep�esen�a�ives of�his Couniy�o emer upon the � � ob e-me ed pro ty r�nspection purposes. � . . . . . . ����,�r c�� /��_g� SEE REVERSE FOR EXPLANATORY LANGUAGE S`�_ igno�ure of PermiNe . � .Doie � � � - v s � y o z � .G.� D G � N N � � . D O D `�1 ^1 W � �n "o -p fr1� 'Q � -NIN r i N Z � a Z C D 9 . . �p . � � T 9 � � � � ' . �_. .. �~ � A D �... � � N , � i� m 9 . " , r._- p N ,1 .. ,����..� � . O Q � � r � .. - �'' � d m Z •! � a 1 � m . � - - � � �'+ _. �-- � o ' - -� . � ' ' x o . `� _ , ` _, � Z , N - _ • �. ,, �'-� m � i t •�' , , � . , i� y' y` . � . „ � - ' � �.f '. 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