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HomeMy WebLinkAbout1198A � .. ��WORKERS'COM7ENSAT104V-DECtARATION � . � . APR�iirPqTli.l� FVE€P��M����Y P�Ii[YI�T 'a ' I hereby aff'vm that I have a certificate c£r,onsent fo self �bp��q - . �_ ._ insure,or n cMtifitate of Workers'Compensption fnsurance, � CE&t7(REY.��IQBt) � . � � � . .. � . - . .- . . . - - . or a certitied copy thereof�Sec.380�Y,tab.C.r Cp(lNTy QF[45 ANGEEES 6UIlQlNG AND SAFETY � P❑oficy No. :.. Company r fi�'_����� . . .. . . . - . � � � 7.�j - Cerhf�ed copy is hereby furmshed. C� � FQR APPLtCANF TOfILL IN(PRINT OR TYPE) AQIdREss Q � !QQ _f tiJ t� .. �ertFfted copy is filed with the county buildmg inspec- � . f.. �� �'�. - � - tEon depwfinent.. , - . �NUNBER -FEl(TUREORfTEM- - .� FEE � - � `��� . � . . oare7-��� ,o�at�4aFlr t4N��/'V ''L wnr€rzcti�� �Z "— �nrc€sr .. .t� � CROSS SF. IC I� L�� . . . .. � . .. - -� CERTffiCATE OF€X€MPif6N�FRC)M Wt3RK€RS`. . .� Z�' BATNiU9 � � F . COMFENSAFKN4 ENSURAfdGE� - � OhVNER - �: . (Thls.aeHon n.��wr h.eamptat•d if tha vm�ic imrotvad by 5htowER � � th.p.rn8r t.fe.an.6und..d dalldr.(Swo}o.las,.1 � Zi � wvaroar . - t2, '��`. q�p�RESS�•' � /j ��°' -�-Gl/+� . ` 1 cerfify khat€n the�rfarmance of the work for wh4ch this - - �- - � � - - � � � � -y � permit is iss�ed,�shall not employ any person-in ony manner � �� . - . ..�'�' GFTk �.T�-�. - . .. . - so os to hecome subject to fhe 1Ncxkers'Compensation Lpws. pfSHWASHER - - - - '�- � � � � . , . /t f, - ` C4NTR.4[T�R _- QWa�?�S`�.SCpplicant ��u�l�/ .-� CLL}THESWASNER � - � .� : � . _ - � � AQDRESS . .. - �' "CE TO AfWUCANT, if, after rzwkmg�thus Cert�ficate af _ ._ SwtMRu�iv(�.REfEPtt?R ��_ : , . .:_ ; �:.- .-.- : .-._ �_` �' Pfton.,Y4VsS�iP4elCk.:.Ei4C4�R 3A3�lCGF,�?�..t�.t$..-:,�P�k9tA .__ -:_. ._. . . ._ .. . _ .�.:. - - . Compensotion provisions af the Labor Code,yau must farth- -� .. � �x�� ' -- - - � .- �'�!����_���. -T _, E..__ . .,. _ .____�, LAWM1f SPR(NKtER SYSFEM with mmpfy wifh such provisions or this permit shaff be - � .. .. - S7ATE -- _ .uC . .. � - � deemed�evoked. wa�rt HEarHz _ uCENSE taa. � � qqss - �� - UCEhtSE6 CONfRACTdRS t?ECtARATiQN . . . . -oisirricr r�q.. � - rROCESSE4 er . � � t hecehy affirm ikwt t artr ticenseti under perneisic.€�of Cfs4pter 4.-�.. .t ... Gn5 SVSrEnt �OUttEtS . � -�. . ... .. � . (commenting witN Sectiort-SOOp)of D'evision 3 of khe fiusiness OU7tETSOVER � . . .. � : �.�,. � -� �ndFiafcssiot�Ca€I�.a�raXl;cense�infulftQcce:ar��ffect� . ecERSYSTEM _ �r-thtat, -� �p '� � . � Y/��FiATfON � 0 - . .. .. . FSATE.,�... �T.j ��,�. ... . - license Number�1����� Eic.Glass� -� - .�.. . .�. ... ..- . .. . . . ..V . . . �. N,� fINAL - - . . . . #. ': - Contractor�..1"t+�����`� � .-Qafe ���—�`�� _ . . � . . �� _ BY :. . �� . . . ._.. 4 i . � - � .,... .. . - ..- . . . � . . . .. . . . . _V i �f am exempt under Sac . . W j . . . . -. .. . - . G' � -. �. B.&P.C.fai fbis reasart- . . . . . . - . � � . . y Plan check fee z ' _ ^ ! . . Qate: - .� . � ...:. -PLUM84NG PERNUTt55UINGFEE& . �'V .. .�. - . � .. � - .. .. ! .. � �Signatsera . . . ._ � +� . . � _ - � - .� .. . . . .. - . . ... - _ .. � - TOTRI Fff � t� �Q . . - . .. _ . .. . . . . . ... - � - .. .. � Ptan check appfimrt � � . � . - . .. � � � c'� � Q,$p � SINGlE-FAMt1K � - . . . H6ME QWh}ER BUIL6ER DEClARATION � Name � -� �`� • � • s� i6y offirm tF�t�]am exempt from tl�e�Corttroctar's Lecense -. ,_�_.s._ �.._..��_T.,� , . <,_,�..�_.__�:.:��_K��.,:�,�::�:.,N.=:.� � l .. far the�nkow'ing ieasan-{Sectian-203t_a'�,8usin�s.`s flnd"`�:. . -�� �a,�..y. �',*������_.,.—•.�.:.y;.:�i P{QfMi�4fI5�f1(�@�:"�". - . . . . �1�Y ... . . . .. . . . . � ,._ . . -Tel.No. .. . ._ _ � � . . - .�I,.as uwner o#the property,witl-.do the work ar�d the �� �� (���' __.strUctu e i�nW-i�tended-or.oEFered Fo�sale-�ESectiiron-�. . . . . � � � - ._ - _�- .. � � Q 7�j��8 r� -. . �. 7[149.8usiness a�!Profession:Codej. - . .. - .. . . . ...... �CCJNSTRUCTION LENDING AGENCY - - � � � � �- . . . . � .. .. � - . . . � . . . .. -1 hereby affirm Nwi�there is o mnstruaion-lending agency for � -� -_ - ' . - . - - - . .. �� .the performance of the work for�which this permit is iswed - � �. _ . � - - � ��(Sec:3E147.-Civ.C.j. ' � � . . . . . .. . . . - . - . . . - � . . .. - . . .. � -j �tenders-Plame-- . . . � . � . � � � � � . . . � .� Lender's Address � : . . . .. . � � � .. . ; i crstify that 1.have read th'rs application ond state lhat the . . . . . . . . � . - . : . abave infurmation is correct.I agree ta compty with all Cvunty ... ....- . . - ..� . � - r ordinaoces and Stare bws regutating Plum�ing,and here6y : - - . _ . . � . � . � - i �.ouFhoriie.represenfotives.ot tfiis Counfy to enter upon the � - � � - � � - . . . � _ ; � obove-mentioned property inspaction purposea � � �- �� - - � - . .. - . �5...'&-�r SEE REVERSE FOR EXPLANATORY LqNGUAGE � Si n e c�f PermiHee . Date - - . . � �. .� - .. . � � � .. � - - � . . � _ ��; � � sa �o�� � � V � v C ID m . , � . � �O ,4 a d Jt � C C'� . . . . N C " 4�? 6 � N -p � O N '�C^" '^N � Ofl',..� � � � 0 =.r.N S ' , . 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