HomeMy Public PortalAbout10714 ARROWOOD ST_Plumbing_8/1/1980_gas system (2) WORKERS'COMPENSATION DECLARATION 7eae67A pp p �p p � p R Tj
I hereby affirm` that I have a certificate of consept to self CE:s'n (z=eo) �P P I��CA��®1�"I F®'R P L�U M P I 1 V . USC 9�7tl 0 II
insure,or a certificate of Workers'-Compensation Insurance,or i
a certified copy thereof(Sec. 3800;Lab.C.) �^
COUNTY OF L GE LES UILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT�1� YPE) BUIL I
AD SS / 7
O Certified copy.,is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
LOCALITY
kr
department. WATER CLOSET N nk
Date - Applicant NEAREST
BATH TUB CROSS ST. W-451-77- '— ' ! Nie- ,
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNERJ_ rS
MAIL
(This section need not be completed if the work involved LAVATORY ADDRESS &}i
by"the permit is for one'hundred ;dollars ($100) or less.) SINKCITY O
TEL.NO. O
I'certify that in the performance,of the work for which this DISHWASHER
permit is issued,T shall not employ,any person ip any manner CONTRACTOR O
so as 19 become subject tot rkeis' sation CLOTHES WASHER U..
ADDR
Dat ' 0 ApplicantUJ
SWIMMING POOL RECEPTOR } W
NOTICE TO APPLICANT: If, after making.this Cert fica e of CITY 6—
,
Exem tionou'. should become ,subject to 'the'Workers' LAWN SPRINKLER SYSTEM- Z
P Y J STATE i LIC. _
Compensation provisions of the Labor.Code;you must forth- LICENSE NO. ®�S�(7 CLASS C .�O
with .comply with such: provisions or this' permit shall be WATER HEATER
deemed revoked. GAS SYSTEM. OUTLETS DISTRICT NO. C SED
LICENSED CONTRACTORS DECLARATION. OUTLETS I't
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
ness and Professions Code, and my license is in full force and DATE VALIDATION
effect.
PA
License Numbeo,2,.s C�ULic.'Class C �_tf BY FINAL
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ContractoAn Sn6 gi-rr4Ae g I "rC)
I am exempt from the licensing requirements as I am a Plan check fee
licensed. architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my,professional capacity (Section 7051,.Bus-
iness and Professions Code). TOTAL FEE 4
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name '
•I hereby affirm that• I am exempt from the Contractor's. Address
License Law for the following reason.(Section.7031.5, Busi City Tel.No.
-ne.ss and Professions Code):
0 I,.as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section'7044, Business and Professions Code). 1 '5; A-7 A
CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 rj
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 2 0 0 �-Q.Q 0 .
issued(Sec. 3097,Civ.C.).
Lender's^Name o 0 0 1Q'0•0 U
Lender's Address 0 &01%:a O
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representa 'ves of his Cou y o enter upon the
above-mentioned p erty ins p n r�pyoses.
�COJat�? f V-$(�
Signature ot Permittee Date