HomeMy WebLinkAbout103 CANNON RD; ; 80-235; PermitCONSTRUCTION LENDING AGENCY1 hereby affirm that there Is a construction len-OF THE GRANTING OF THIS PERMIT.APPLICANT'S SIGNATURE* X" ) / j OWNERQ CONTRACTORQ' ""• '-J AGENT_$[ BY PHONE QAPPROVED BY DATE1CERTIFICATE OF EXEMPTION FROMWORKERS' COMPENSATION INSURANCE(This section need not be completed if the per-mit Is for one hundred dollars ($100) or less).1 certify that In the performance of the work forwhich this permit Is Issued, 1 Shall not employ anyperson In any manner so as to become subject tothe Workers' Compensation Laws of California.NOTICE TO APPLICANT: if, alter making this Cer-tificate of Exemption, you should become subjectto the Workers' Compensation provisions of theLabor Code, you must forthwith comply with suchprovisions or this permit shall be deemed revoked.1 HAVE CAREFULLY EXAMINED THE COMPLETED 1JAFHEREBY CERTIFY THAT ALL INFORMATION HEREONFURTHER CERTIFY AND AGREE IF A PERMIT IS ISSUECOUNTY AND STATE LAWS GOVERNING BUILDING CCSPECIFIED HEREIN OR NOT. 1. ALSO AGREE TOSAVELESS THE CITY OF CARLSBAD AGAINST ALL LIABIL2±zzb5*
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A WORKERS' COMPENSATION DECLARATION1 hereby affirm that 1 have a certificate of con-sent to self-Insure, at a certificate of Workers' \Compensation Insurance, or a certifiedjiopy^jthereof (Sec. 3800, Labor Code). V* ^\ \ ^tPOI ir.Y NO X5vV \ ^.REMODEL/ALTER PER CIRCUtT,9U3A033N33-
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. m 1LICENSED CONTRACTOR'S DECLARATION1 hereby affirm that 1 am licensed under provi-sions of Chapter 9 (commencing with Section7000) of Division 3 of the Business and Profes-sions Code, and my license is in full force and ef-fect.NO. .^ y^jL/yt^i^tf-/^ JOB *ODRESS/^{•^ r^r\ i i i i i i i i i i i i i i i i i-
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