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0764A (4)
:,� WCIRKER$ COMPEMSATlON DEt7ARAT16N� - � � P9P�L1CAT101lI-��4E2-�Pl,!l1VtBl#�I� PEP�.�J-lIT -_ _.� .-. . - - - f herehY affeem thot t hqve.p.4e�ttfiGQE�_of zqnse�l,to saff ��zp - .__ xnsuce-0c�cerufrcntenESalnrkeciCompensar;anlnswiuug, --C€B��-(RE}F.t�sa})--- - �- . . .-._ .-.- ... . — ---- ---- --- ._ .__ -- or a cert�t�edeupy+heFeos{Sec 38�,la6_C)___ COUPI�YQF�t)SAN6EEf5 -- - $UIEfTING/kN�Si1FE�1f __ :4. _ _ _ -- �cyNo. ..- . ..Compnny �. . . .�.. . . � .� -. . � .. �._ .. �. _. :-- . . .. . , - .... . Certified copy is hereby furnished. . � -- FOR APPLICAM TO Fftt IM(PRIMT QR TYPE) 9UllDIMG �. � Certified copy is filed with the county 6u4lding inspec- - . AODRESS - _ - NUMBER FIXTURE OR ITEM t�'�_. � ` - .. .tion deparfineot. � - (� .: FEE � . - Dpt�ic-�L3---G-.�-Appii4ont .��-L.a� . � WAtER CCQ$ET . ,� � - . . NEAREST �� ... LER7FFtCAIEGtF.EF:EMFIkQN.F&4MWORKERS' 2,.r- BATHI[tB. . � . ,Z � CROSSST.� ' . �- � � � -GOMPENSATION INSURAM1iCE � - . � � - pyy� � . . . � (ikis seeHoe teeed eof�6e tniupL�etRd�if 4ht+eeork-ierelred-h�r �� SHOWER - .. -. .. . . 14 A4All . fhe pam�if is for O�hvad[ed dollars{St0lF}or�ss.} � ERVAiORY . . . �, AODRE55" - .. � � 1 certify that in the perEormvnce af-the work fior whicfr this � � . . . -. . . � �� -� permit is iss�ed,t shatl not emplay any person in any manner -�� �� � � _ �. � C�TY- ' - � TEL N£}- . �- - : , so as-tg l�etame sobject to�the Workers Compensatian Laws. . -� � � � �� - . . . . _ ._�� : W5hIGVA4f�R � . . •••• C�IVTRACTOR � - . � _...-. . � .pcte � 4ppltmnt r CIOTMES WASHER . � - . � . . ___-. . _ . RD�RE55 � -. � 'ICE FE3 APPUEANT: If, p#ter muking-this CertificaEe of . .. . . :; .- -- -:.- --. .I: _-- , _„ ' �� � �. .�-__ -. -�..,._�.,.,,�_,� __.ms _�.,.� .-- � ...vW. _ .._ .n .npticfn. Yfsv-3hFr€�#d`tsecott+�--+�UE3[CE�#s'��Bxkess` . ,- __.._ __ _��� . � TE{..M1IO. . sv � Comper+satsan provisiorts�of ttie Cabor Cade,you must farth pqqyN�i�KiERSvSiFM� � �- � �- with comp�y-with s�ch._provisions or this permit shalt ba � � --- STATE �� LtC. - . . � deemed reYOked.. . - . . - WATER MEAiER . . .. . ..1 . : .^. �IKFNSE NO. -: - CLASS . ,': �L{CENSEE�CQNTRACFORS 6ECIARRTlON � '� - DISTRlR NO. . VROCESSED SY� - ' - lhetebyaffirtntlmttamlicen;Bdu+tderproyrsiartsofClXapter4�.. �-� Gn55YSiEM .. OUttEis : � F�-- .. .. .j�_ . . . --� .. �:-.-i - _ (cammerrc�ng wfth Section 700Q}Qf Oivkian 3 nf ihe Busneu - OuitEiS OVEa . . f � y.-� arid Pr4fes��ans Godee stnd my,licens��,s in fukl fflrce qci�d effect. s�a SvStenn ' °5 t3A E� � �-• VJII.ID�1TiQli � .� '''jG �' �r�� _ - i � Litense Number�� `���` lic.Ctuss� - - � . ..'3��'��� `' � _V . . " - . �.._. . -. I . _ _. ���� �� ... Q . �. . PINF4L �� . _.. . � . _ ��. 1 .� Confra���,:+�t`w'�+x"=�A� Date� ��-Cy� . _ .. ..._ . . BY . ."_1--- � . . . . . . 4 . t i . .��� 1 am ezempi.onder Sec -. . - . . . . . � .- . _ - - ' . - . � W�:. i _ . . . _ .. . .._ . _ -� � - � - B. -� .. -- - - 8.&RF.Iw this�easan . . .� . . . -� .. - - - � y ' - . . . . --. . . . . P�GtD CIi@CI4 fC6 - _ � . � _. - - . . � � - � � � � - {?Ote: . ' . . . �. - . �-� - . .. ' . - 7 . . . . � �-� . . PLUMBtNG PERMIF ISSLlIfdG fEE.¢. _ . �i`.1., . . �- . . . � � . . � � . _Sigoature :_ .._�_ . : . . . . .. . .� . -� _ _ . . . . . TOTREPEE _ :. .. ._ . � �-c.C1�GG-��A- � S � . . - .. . . . . - PICn[heck appiicant ._ . . . . . . . . . ! . SINGLE FRMRY . }r• • • :e�� - HOhM1E.ClWNER.BUIU�R DECLARAII6N ..,. _ . Name ._.� , ._ _ ' ..- -'-' -� - .� __ __ . ,. . - . � � eby flffirm t€xft 1 am eacst_ryN�ram ths.eorakacinr'3-L�cense �.-. ���e�s : -- .- - - -- " �LL__ -�-_.�...;a i.�.�a��.�}_.. �. -.-.....' ... . . _. . . . ., _ :_ ._. ,. .n... _ ._ Eaw for fhe#ntlowing revson�(Sectian T437.-S,-B�siness and � � �� � � € . .(P�'ro�fessions Code}: . .. . . . . C�ry-._.. . Tel.No. - � . � r;o ��E:;'.v v f t�t: i,ae owner of fhe o r 1!da the work aad the � .. . - . � � ... . � - � ? a�e��r,w� G b 1 7-�5 i - - structure is not ietended pr affered for soFe (Section � . - � . .-.. _ � . - - .- . _ , - 7044,&usine;s and Professions Code). � � - - - . �__. - - - - - �ONStRtlCTION LENDING AGENCY - �. . - . . � � � ... .- . � . . . . _� � ��. . -1 herehy nff"um thot there is o construction ler�ding agency for - � � . . - . .. . - - - . .... ` � � - . .-ihe perfprrtwrne o#the work for which fhis permit is issued . - . � - . � . . . - - � - . � . - .. � .:(Sec:3Q97.Civ.C:): - - . . � . . .. _ _ . . . : - . . � . .. . LeadePs Nama � . � � . . . . � . �- � - �. . ... � . . � �- � - .. Lender's Address � � . .:..- � � ... . . . . ... ..- � . . � .. � � t�certify tFat-1 have read ihis applicpfion and sfate thak the - � . � � � �� - � - � - - .. . . ._. � ,abave informwtion is mrreci.!agree.to comp(y with olt County � _ . ,� _ . - � . � � , - . ofdinances ared Stote lows regulating Plumbing,and hereby - . � - � �. - . . - authorize representatives of ttiis County to enler upon the . . - --� - - - . � - � � . . � � � .� � ohove- ntioned property inspectian purposes, � -� _ . �. � � � ' SEE RfVE(t5E fOR fXPLANAT4RY LRNGUAGE . �-r-�-4a� _ . Si na e of PermiRee - - Date � _ � . - � � . . � � . "�n �.„ N 9� �''�� u� O ' ffi � � ` u O p�b 'p 3 a�. � c � � ao�o „ �o � o� � o c Y O'" m e=L , ' � r. ..y,ro b� c �o ;c`ns.c o .ti nm °b � o ° o � m rn° c c^o o "' 0 3 m,mc p'ti e.a 0� Z � � � > [ ^ > E ,� o e �4. .c o�' m.°c d ,smF � _° ; � r o p v.9 0 � o m e E o >o . � `� � a,°.o `n o � c o,.o a o o e '� 3 > i " a h .. 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