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HomeMy WebLinkAbout1202A (6) ' ,:�.,..:,. ._.:. ,_:..m. _��..,�,._. . �_.��.�>� ..r.�<,:.�:�. „ ,_ .�. - .. ...� _...... . _ .. r , .. ... . .... � WORKERS'COMP�N$ATIbN�ECCA�R�P�N APpLICATl�3� �2�R F�L��BII���'ERAAIT� � 1-1 I hereby affirm thot I��ho e p ceriif cate of conse�l 10 self 20-0026 DPW�S/87 . � insore or a'tert f cote of Workers'Compensation Insuronce, 76A667A . , , � � o o-cer+�fiedcopyrhereof(Sec 3800 lab.C.) , '� " "" �` """"""'"'�" �/��� COUNTYOFLOSANG�LE$ DEP�'f' dF�PUBL�CTlVOI�iCS POofity No.�A�yW.�[[c.ompany .�� Lusrli� . . .. , , . � . _ _ ..a Cerrified copy is hewby furnished. �-� -��� - �� � "� �� '� FOR APPLICqNT TO F�LL IN(DaIK1T"f?R"fVA�'1� �`�" BUILDING � � � Certified copy is filed with the couNy bwiding inspea � '� - ���'� �� �-� �� ��`� ' ADDRESSp� � . v o � . tiondepariment. C NUMBER FI%7UREORITEM e FEE �,OCALITY ���� a��� Dote�Appl�4ani��N���,n .F.,S,F-s^fi : WA�E0.Cl�5ET ... NEAREST � � . . � . , ..: �:.�.::.:o. Ck055 5T. � 0 G� ��{(- '� � ,CERiIFICAYE`b�f�EXEAtiPfI`d�€RO"l�17JCS�nR`�CET2$., � _. earH 7UB � �� �� " COMPENSATIpN INSURAN�E�� SHOWER OWNER o ,j ���.L ' �� (Thfs�adion nead nol b�eomplafed!f The work ievolvod by ^ �~ - th�psrm{T Is For one hundrad dollar�(5100)ar less.) �n�AiORY MA�� ADORESS A 6 (O (�Q/f �'�I certify fhat in Ihe performarce of the work tor which this � perrrii�is iss�ed,1 shall not employ any person In any manner SiNK aTv TEL NO. . 'so as to become subject to the Workers'Compensafian Laws. ���~ , - DISHWASHER tOMRACTOR . . . . . . _ . ' , . . . . � �7 � � �ate Appiicani � CLO7HE5 WASHER �� ADORESS a , ���NOTICE TO�APPtICANt: If,�oiter`mak ng this Certificaie of � � d"Y ,2/+/ft.� .�,Exemplion, you�should become subject io the Workers' SWIMMMG POOI RECEPTOR� � � ����Compensalion provisions of the Labor Code,you must forih- � . . CiTY �T TEL.NO. IAWN SPRINKLER SYSTEM "- �� with compiy ifh Such provisions or this permit shall 6e SiATE r�LIC. . �deemed revoked. , _ WATER HEA7Ek L�CENSE NO.` � � d.} CLASS — � ��LICENSED CONTRACTOR5�DECLARATION�- oi57RiCr No. PROCESSED BY I hereby of�irm fhat I am licensed under p ovisions of Chapter 9 GAS SVS7EM OUTLEiS ,� Cli� 0� �� � � � �(commencing with Secrion 7000)oi Division 3 of the Business OUTLETSO4ER � � and Professions Code,qnd my license is in 4ull farce and effect. 5 PEa SYSTEM PIN l �" ;., . ,,� AIIDATION p; �. . . . . . . . ...�.> DAT�,�� License Number +����� Lic Class_�>'� U� �. � � t � �j�,, FINAL �omrocror �� ��ate �-'Z'�`� BY _, ..,, � ❑ i I om ezempt onder Sec U W a.aa:c.'fo�r6is�eason plan check fee � _ Da�e: ,. .. ... � � PLUMBING PEqM'Ii(SSUiNG�FEE S���� �? �U � � Signdtuie �8�'� � . iOTAI FEE %� G Q 2 A �. ...� . . . �.. Plon chetk app�icont ... .,.... '{}'o s � a o'j �. .,.-..`. . � � ._,. ,..... �. .. SINGLE�FAAAILV � . . ..."`" . ...." "" ..,.. : " �� � � HOME�DWNER-6UILfJER�DECLARATION�- � � - ��� Name „ ( , a � �j�, I hereby affirm ihpt I am ezempl from ihe Coniracfor's Li<e�se Address Law for�he 4ol�owing reasan (SeUion 7037.5, Business ond . � �, �., y 1 Professions Code: ' S.`.'" Q... ) City Tel.No. . ..... .. .........: _. ._...F .. . I,os owner of ihe property,will dn rhe work and the ��•�E'�&`� structure is not intended or offered for sale(Section � � 7044,Business and Professions Code). , ; , ,_; , � � � . ............ �.._., .....:. .. . ,.... . . ,_ .._.... .., ._. ...,_ . .._.- ... CONSTRUCTION lENDING AGENCY �hereby affirm�hat there is a consiructian lending agenty for fhe performonce of rhe work for which this permi+is issued (Sec 3097,Civ.C.). . . . . . . . . ' � . . . ... .._, . Lender'sNome - . , . . ,.�... '..w�,,.--..�„�...,�.,,o,a„,, ..�.�........:.........-,.�..r.�..,....�.J.:.,.....�,..,.__.,.._...._«..,.,�.....,.,,.,... . Lender'sAddrets - .�_..,4-. ..-...__>.+...�.:, :z,�...,,.:.,,:. — -.,.-wf�-�.�:.,...�.,..n,m.,.,.. ......w. .,:>,...,� ...�.-.,..__�.. .,......_... .......... ,..,.........,..... I certify thar i�hove reod 7his applicarion and state that+he � � � . above infor �tion is correcl.I agree ro comply wirh�II Coun?y .� �ordinonc d S�ote lows regulating Plumbing and he�eby � a�+hon r presentotives of tr�'s Ccunty to enter upon Ihe - � . ........ _., ._..,.... . . ...... ...:.... _..... .... .......�,.�.... . _ - abov m nt oned'prop ny f inspection purposes. . . _ .- . � ....-�.. - � � � � SEE REVERSE FO'R EXPL6i`I�fAY`ORY'CAIJ��s`UIL�E � a i f. � s oture of Pe�mittee ' ote �. . � � � � � .. �_;....�..�... ��,., :��.��....,,.. .,�.<�".«w..�:.5.�_.",�..Yn.1..e.,Fv.+�^ �' �..�' ds�'3`135��=��"`3'`.�'.' '�.'�4?L'.� "�"*b"�'� ' " �... .� .. ._,,.� _ w.e �.. 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