HomeMy Public PortalAbout5232 MCCLINTOCK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION raaesr(I APPLICATION FOR 'PLUMBING PERMIT
I jrereby of firm that I have a' certificate of consent to self c� err z-eo
insure,or,sicettificate of Workers'Comp cation Insurance,or
loertyi;.�
3800,La �, COUNTY OF L S A91 'E,S.� BUILDING AND SAFETY
Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /
Certified copy is filed WiQ64e coon y buildin inspection
NUMBER FIXTURE OR ITEM • FEE ADDRESS 6-A3GcY.• f
d part e it s WATER CLOSET LOCALITY
N "M"JO C•1 T
Dot e Applicantq!v EAR EST �3
6 BATH TUB CROSS ST. .e
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER R o Sl��is?L_O
(This section need not be completed if the work involvedMAI L
by the permit is for one hundred dollars ($100) or less.) LAVATORY �� ADDRESS� A4�(. L./�`
}
SINK CITY 111r LIJJ . ITY TEL.NOJ4s1„_ lq O
I certify that in the performance of the work for which this DISHWASHER U
CONTRACTOR
permit is issued, I shall not employ any person in any manner /� �® s
so as to become subject to the Workers' Compensation Laws. CLOTHES WASH ER Jgi0
ADDRESS 5-3 0 4;;7, O
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY �CN,06)� TEL.NO.'?3S--V
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM ate`u [—
Compensation provisions of the Labor Code,you must forth- WATER HEATER LIC NSE.NO..G.® -/y LI ASS. 13-1
with comply with. such provisions or this permit shall be —
eemed revoked. GAS SYSTEM OUTLETS DI TRICOT NO. OCES/S D BY /
LICENSED CONTRACTORS DECLARATION OUTLETS OVER V `�/ d" L%e���GCIiGv
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL / % / VALIDATION
ness and Professions Code, and my license is in full force and DATE / Y ✓ �r
effect. ii [— d
�4 SS" !3 " 1 FINAL ` �,�, :s..r.t
Li�l se Nu ber Lic.Class BY
��%\����,� / I
orttract0Tr ate
❑ lam exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE `
Lic.or Reg.No. Date Plan check applicant IRR-2211,9A
HOME OWNER-BUILDER DECLARATION Name # 0'00 - 5
I hereby affirm that I am exempt from the Contractor's Address 440 1 9.00
License Law for the following reason (Section 7031.5, Busi- City Tel.No. 0
ness and Professions Code): o 0 0 1 9 0 0 L
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 0 923-80
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
Lender's Address
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 representatives of this County to enter upon the
above-mentioned property for inspection purposes.
Signature of Permittee Date