HomeMy WebLinkAbout1419A `"°RKE"5•`°'"�"�T'°"°E«^R"T'°" APPLICATION FOR PLUMBING PERMIT �
I hereby affirm thot I have a cenificote of conaent to self 70-0026 DPW fiJ87
ins�re,or a car�ificate of Workers'Compensation Insuranc , 76A667A n �v
or a cerr�tied copy rhereo((Sec.3800 b. .) COUNTY OF{.QS�MrCaE�ES � DEPT.OF PUBLIC WORKS
POolicy No.�Company � �.�I
Certified copy is hereby furnished.
FOR APMIU t T
Cartified copy is filad wirh the couMy building Inspec- NUMBER FiXTU FO 1
lion depa�tment. � �
�� WATERCLOSET �� t
pote�Applisanl , [EROSS S7. L ►L �
CERTIFICA7E OF EXEMFTION FROM WORKERS' Ba7H TUe
COMVENSATIONINSURANCE SHOWER OWNER -
(This��dlon n��d nol b�compla}�d if th�work imrolr�d hy �i�
tM p�rmtf i�for on�hundnd dollon(5100)or lua.) tqvntORv ppp�� �
I tertify that ia the perfwmance of Ihe work for which this
permil is�ssued,I sholl nol employ ony person in ony monner S�NK CIT � � , TEI.
so as ro become subjeci to the Wo.k rs CompenwY a Lows. D�SHWASHER
CONTRAC70R
Da�e y_��9dppliton CL07HESWASHER pppRESS
NOTICE TO APPLICANT: If, aiter making ihis Cerl' ale of
Exemption, you should become subject lo the orkeri SW�MM�NGPOOtRECEP70R I,'
Compenwfion provisions of the Labor Code,you must forlh- ��TM v�,! � ��'�'
willl [omp�y wifh S�ch pro�isions or Ihis permit,shall be �'4���NKlER5Y5TEM
SiA7E LIC.
deemed ravakad. WATER HfATER ������ QASS �
IICENSED CONTRACTORS DECLARATION pis� gy
I hero oHirm tiqt I am linnsed�nder �S SYSTEM WTtfTS �
by provisions of Cfapror 9 - o
(commencirp wirh Section 7000)of Division 3 of�he 8usiness . p��1E75 pyER
ond R�ofemions Code,ond my liceme is in full force ond effxt. 5 iEP SVSTEM F�N� C
DATE � a`� S VALiDATtON �.
Licenae Number�Llc.Closs� U
fINAI !/�,_ O.
Cantrocto Dote BY �VL� �
❑ 1 am exempt under Sea V
8.6P.C.for+ ' OW,'
Plan check fee . � tn
� � PLUMBING PERMIT ISSUING FEE S a .r.��/ � Z�
Signoluro �/ ,_/('
� TOTpI FEE /" �' �t a 1.9 A
Plon check oppllcan� ' ' �'' �y • �Jr . .
SINGIE FAMILY I•��Jr 7.O O
HOME OWNER-BU4UER DECLARATION Nome - _. .. .
I hereby offirm thot I am e�emp!kom the CoMra�or'S Liceme qddrass •�''S�•n��
Law fw�he following�euson(Secflo�703I.5,Busine+s ond � '
Vrofessions Code): Ciry Tel.No. �Q.Q J��a 9
❑ I,as owner of rhe property,will do�he wak ond�he
eeructure is no�Imandad a offered for eole(Section ,
7041,Business ond Rofe:sions Code). �
LONSTRUCTION LENDING AGENCY '
�he�oby offirm�hol there is o conshuc�lon lendi�agency for
�he ppr/prmonce of the woh for which Ihis permit is iasued
(Set.3097,Civ.C,J.
Ler,der's Name �
Lender's Address
I eerlify fhol I have rcod this applicotion and�bte Ihot the � .
above�nfamm�on is cor.ec�.I agree�o comply w��h all Counry
ordino d SIa1 lows regulati lumbing,ond hereby
aul re enl es of th' ounty lo enter upon 1he
- e ' e �pr ty f nspedion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�grro�ure of Permine Dare •
n G
:C � r �c'- i�
� �y p
G y G � G "� in Y
w+ � � . i (" 1� � J T
`�,: 7 1 N�'., W Y� Z�i 1� � d 7J
:.ii Y_ n � 4� � � � � �
`�'u+ O " Z ! i` Tr
p'� ' � � �� � �f
' 7?�r � �.'� N
V �. �,
� 'ti, O
, �
� � a
- m
i� . �.
J �,, . �
� - . � �,.. � " C
t' �1 • `t " , ~�1 (' M
w \ �
' " ~ 1
,\ - a ' � ' \ �
' / . V'
,1� . � � ��
� �1 �L
� R� " ?�
G
�� O , m
�? .
. N
. O ,.
a
� � � ,
• \ :
. � , \ � � - -
, � �
o �
�
� � , ?O
. �
. �
r�
O p C � �.
v,n3c. .,c� No
. - : � o � � n �; c.`
♦. `� O O C.?,�• v,-p tp V�
G v f^
. . . � N;J, U� W S� O o Q �,�.' fl p{^ �.
? "' � w? 0 • !
, ' � y p �„ l? p` V• �j fj �y O Q p.tl G �,? •
y �' t1 N, f1 N O Q' C.O ."� 7 t� �, U L
' +�L'C7 � T O �p��J jn 6.G ���V t�N�'3'-. �n � O � �;V
, L� Q Cf .�.� � n�'C'7 '�'� � O�+�C,b O �O — � G O v� ��� G
U ' ?�' 7 . " c'� o'N °N'qa'a. o" `o �'- aD� � " C ^ o Uo r
�, ` � ' 'O f� 6'C• Q � i?.. 1"u� '" `t r 'O b f �c � =0 :� v' �`% �"� . .
OO ^� .C� %^ ° �-�».fl ""o ° � g i � " Q�; �`.' � ; n° � p
^ � � m
� � 7j u' � O � O.N 3 Cl `'j j N � �Z� n� �l�i'7 C' �:
o � .o �. � i� <v o a � � � u, '� n ' ° `� 3 `
' � y � T 4� n � N �-C.`fi ��i j � fl p U� O'.T'ci'O ,�
� ' 'v� � C. , p °� 4,� n-N p �o �,p ±c v ,,,'o %.3 � r ,� s� o �,, .
� � �.�. 0 4 ' n �' o °o � -o T� F °, o "` ^ ^. 7 3
- . \ C� N. -. ?�S a 5.n n v^ 3 0 -�c � o�.a � n
1 n c� T o '' " N "�c?..N �, O 3 � �' °o' ...r , � �� "?.
. ' , o n c� tY O ±,c � -t p < � : < . "' c ; „
�..'!� c'1 O '
� y? ' � 7 � � 7 v� P < r -- !'�
' .. . . C ��- O`;�? a ry P-% `� G-=.> r j �'.c v n c � � �
. . \ ' p, v, O ` .
� �(> �L Q 3 p Cy ,� l� o O i�j ;�;t^J G. -' .1
� D.�' �b U'� � C V v� 7 � n n O �a� 0 ry
. O� � � 4 < 7 ^ V "� G O n' C_.� ��„ �O i rt.4�� �
. . _ „� ,O "" C 3,lp „� �Q . G .7. � "' .0 t�. O ` � v,u
' ' . N C O`.'��-3 O ? 'f. ?fi '�� O S � n '1 �i
' � , �� � �' �7.0.�d � p G C r. p .' c�
_ rj 4-U C N �•� 0 T 0.� U V, N � f�
. . , y q� �^ N Ov LL n C = � N '
� , i V � �p ) 1 .
, , . , s> j � , n.
� ' � o � � .
. � , . n-=r o .. "
- ' ��