CITY OF OCEANSIDE
DEVELOPMENT SERVICES
300 N COAST HIGHWAY, City of Oceanside CA 92054
BUILDING INSPECTIONS (760) 435-3925
Applied Date:  12/29/2022
Expiration Date: 
Permit No:  FIRE22-0338
Permit Type:  FIRE HYD FLOW TEST
Site Address:  4002 VISTA WAY OCEANSIDE, CA 92056-4506 Site APN:  1660104300
Subdivision:  PARCEL MAP NO 05632 Site Block: 
Site Lot:  Valuation: 
Site Tract:  Permit Status:  FINALED
Description of Work:
HYDRANT FLOW
 
Contractor: KIMBLE & COMPANY FIRE PROTECTION SYSTEMS
Address:
Phone:
Technical Information:
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Address:
Phone:
 
 
WORKERS COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
____ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
Policy No. 
____ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are:
Carrier:       Policy Number:       Expiration Date: 
____ I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
License No:    Expiration Date:    Contractor:    Class: 
Inspections:
TypeResultDateInspector
FIRE FLOW TEST INSPPASS1/19/2023RON OWENS
Fees:
DescriptionAmountReceipt #Paid Date
FIRE- OPERATIONAL PERMIT INSPECTION$205.00205574301/19/2023

TOTAL FEES: $205.00
TOTAL FEES PAID: $205.00
TOTAL FEES DUE: $0.00
*FIRE22-0338*