HomeMy WebLinkAbout1415AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a.certificate of Workers' Compensation Insurance,
or a rtifieclcopy thereoff (Sec. 3800, L )
,icy No, `''Company
Certified copy is hereby fur. ii k..i
® Certified copy is filed with
tion department.
ate7�+-�%`' Applicant
CERTIFICATE OF EXEMPTI(
COMPENSATION
(This section need not be complE
the permit is for one hundred dr
I certify that in the performance
permit is issued, I shall not emplo
so as to become subject to the W
Date—Applicant—
NC- ` TO APPLICANT: If, after
Ex ion, you 'should ,become
Compensation provisions of the L,
with comply with such provisior
deemed revoked. '
1LICENSED CONTRACTOR
I hereby affirm that I am licensed ui
(commencing with Section 7000) o
and Professions Code, and my licen
License Number— ZII I6zG U,
Contractord%�°OZq�,y
❑ I am exempt under Sec._.
B.&P.C. for this reason
Signat
SINGLE FAMI
HOME OWNER -BUILDER
I -y affirm that I am exempt fro
4a.. .or the following reason (Sect
irofessions Code):
I, -as owner of the property,
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
e performance of the work for which this permit is issued
lec. 3097, Civ. C. ).
bder's Name
rider's Address
`ertify that I have read this application and state that the
love information is correct. I agree to comply with all County
finances and State laws regulating Plumbing, and hereby
thorize :representatives of this County to enter upon the
zve-mentioned property fo inspection purposes.
nature of ermitt a Date
76A667A APPLICATION FOR PLUMBING PERMIT
CE 817 (REV. 10/81)
COUNTY OF OES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
il