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�- WORKERS'COMPENSATION DECLARATION App�ICATION FOR�PLUMBING PERMIT �
I hereby;.offirm rhat I have a cerrificate of consent ro selF in- �A���A��4��
suie,or a cerfificale of Workers'Compensafion Insurance,or a �E 817(REV.BiBb) � . � "
cettifiad copy Ihereof(Sac.3800,lnb.C.)�. ' ' � �
po7icy No.73WC00504299,��yNATIONWIDE � COUNTY OF LOS ANGELES DEPT.OF PUBUC WORKS,
� Certified copy is hereby fumished. �
Cerfified co � FOR APPLICANT TO flLt M(PRIM OR TYPE) BUILDING
�i py is filed with Ihe county building inspec�ion ADDRE55 03 SOUTH WYNNEWOOD DRIVE
`�" departmenl. NUMBER FI%7URE OR ITEM � FEE ��A��TY
WATER ClOSFT(7011ET) DIAMOND BAR .
Date 4-1-88 ApplicantNEW PLITMBING 3 6 1H NEAREST
enrH rue caoss sr. GRAND AVE.
, CERTIFICATE OF EXEMPTION FROM WORKERS' Z iL
� COMPENSAiION INSURANCE � SHOweR � ' ' 12 . OWNER BRAMALEA LIMITED
.(Thit�siction nesd no1 6a eomplaled if ths work involved 6y, M„41�
tha permit is lor ona hundrad dollan(SI00)or las�.) . )r � tnvATORv � 30 ao�aess � 151 AIRWAY AVE. SUITE N
I certify tha�in tfie Performance of�he work tor which this per- SiNK
mit is issued,I shall no�employ ony person in any manner so cirvCOSTA MESA TE�."o.g50-1001
as to 6ecome subject to ihe Workers'Compensvtion Laws. Di5HWA5HER
� . CONTR/+CTO
Do1e Applimnt � ' 1 CLOTHES WASHER 6 qD�RE55 �
�"CE TO APPIICANT:If,ofter moking this Certificafe of Ea- SWiMMiNG POOL RECEPTOR � -
' �ion,you should become subject to the Workers'Compen- Ci7Y 7Ei.NO.
�snnon provisions af the Lobo�Code,you musl to��hwith mmp- LAWN SPRINKLER SYSTEM —
ly with such provisions or rhis permil shall be deemed revok- S7ATE LiC.
ed. � WA7ER HEATER� LICENSE NO. C�A55 _
tICENSED fONTRACTORS DEC�attAT10N 6 DISTRICT NO. CROCESSE�BY
I hereby a(firm�ho1 I om licensed under provisions of Chopler GAS SYSTEM OUTIETS � J�
9(tommenting with Settion 7000)of Division 3 of Ihe Business OUTlE75 OVER �
ond Professions Code,pnd my license is in full forte o�d ef• 1 5 PEk SYSTEM 1 5� FINAL/' �//� DATION }
fect.
. DATE 7/`�'//�y a
License Number 426109 Lic.Closs �-36 V
FINAL �f Q
Comroctor NEW PLUMBING po�e H-31—SH BY /�;<te�e� p
�
� I am ezempt under See. - � �O I��7 a W �
a
� B.BP.C.for Ihis reason � � � � � V1
. Plon check fee , # ^5 Z
Date: pLUM81NG PERMIT ISSUING FEE S - � ° � � �.O O
.� Signarore � . TOTAL FEE � �
114 ^114U0�
'- SINGIF FAMILY plan check oppiicant '
�� HOJ.�E OVJNER-BUILDER DECLARATION . D�� O—H S
I hereby afiirm that I am eaempt f�om the Conlractor's Litense Nome . - � � -
I �fo��he.following reoson(SeUion 703I.5,8usiness and - --- � � � � ,
I Jssions Code): Address
� I,as owner of the property,will do Ihe work'and the Ci�y . Tel.No.
. stroctore is noi iniended or offered lorsale(Section 7044, � . . , �
� Business and Proiessionz Code). . ; , ►
� CONSTRUCTION LENDING AGENCY � � � ' �' �
I hereby o((irm thal there is a tonstrutfion lending agenry for �
fhe performonce of�he work for which�his permi�is issued . - -
(Sec.3097,Civ.C.). � .
�' lender's Name � - � �
Lender's Address . � �
I certify�ha�I hove reod this applicalion ond s�ate thar the � � � - .
obove information is wrrect.I agree to comply wifh all Counry - .
ordinances ond S�are laws regulaiing Plumbing,and hereby -� � �
authorize represenlatives of Ihis Counry to enier upon the . �
jIob e-men' ned property for inspeclion purposes. . . , . ,
�� -�,�.�� ' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitlee Dale
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