HomeMy Public PortalAbout10714 ARROWOOD ST_Plumbing_10/30/1989_sink WORKERS'COMPENSATION DECLARATION' G=�1U"�l���G=t1 11 �OIIV ITO� I1 LU VI1VllIJ�IIV� ��I11����
1 ' a 76A666 DPW 4/87, -. J
I,iereby, c#firm that I have a certificate of consent to self in- `76A667A Cjl
sore,or a certificate of Workers'Compensation Insurance,ora CE 817(REV: 8/86) IL
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F - Date '�1 APPhc nt CLOTHES WASHER ADDRES ' r
NOTICE O,AP ICANT. If, after,making this Certificate of Ex SWIMMING POOL RECEPTOR. V
'emption you should become subject to the-Workers'Compen- = CIT r iEL.'NO.
cation provisions.of the1abor Code;>you must forthwith comp- LAWN SPRINKLER SYSTEM _ Lno
ly'with'such provisions`or this permit shall be deemed revok- STA E LIC.
ed % a WATER HEATER LICENSE NO. `• •CLASS( "��
LICENSED CONTRACTORS DECLARATION SZIN PRO S BY
I herebyaffirmm d
:thdt I alicensed uner provisions of.Chapter GAS SYSTEM.
.
OUTLETS
9(comrriencing with Section 7000)of Division 3 of the Business OUTLETS OVER.
and'Professions-Code,'and my license is in:full.force and ef- FINAL >'
fect. DATE ' Q
ER SYSTEM •
..-.License Number � -" "►"-Lic :Clpss_,� .,� _ f
ALIDATION
'
Contracto �i[ -fate BY AL 0
t
exempi under Sec
UJI
B.&P.0 for'this reason
Fl _
an check fee
' Dat`e: PLUMBING PERMIT ISSUING FEE$
Signature
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T OTAL-FEE
SINGLE FAMILYx Plan check aPPGcantHOMEOWNER-BUILDER DECLARATION
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I hereby affirm that I arh,exempt'from the Contractor'i1icense Name 7
a
Law for.lhe folfowing'reason (Section 7031:5 Business•ond f t'�'�n,r
,Professions Code):' Address "r''f)? 1 K.
�' ..I,'as owner of:,the'property_ the;work'and the City Tel.'No..` 1 ITEMS
structure isnot intended or offered for'sale(Section 7044;
Business and.Professions Code). ��Ij�L 16 m 50'
r V
CONSTRUCTION LENDING AGENCY �a�G{.[1 16s50
I hereby_ ffirm'that there'is a construction lending agency for ° i
the performance:of the,W'ork for which this per ni1'is issued, "�(''
(Sec. 3097, Gv
i 'ry
Lender s,Name• "' VUo l{ 101�V
Lender s Address C}441 d „ ' .AM 8-'�Y::
I certify;that I have readthis'applicahon`;and'state'that'the
above information is correct. I agree to comply with all County D
ordinances'and,State law regulating Plumbing, and hereby m
d �.rt�nt
` Pres ive f'thi§ County,fo'.enter upon they.
oone ro'er y for inspeeti'on pu poses.
%`. •, SEE.REVERSE FOR EXPLANATORY LANGUAGE
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gnature.o mittee ' •D te.