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HomeMy WebLinkAbout0777A -._._ �- 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 ' r C L] 'O S � L] � C a� Z r~`_- cDri C � tDi, v�i �c v . -NI N r --I ; < � L] T tn-� � � � y m .0 2 � D �� A � � m ~ _ � N � v� � T y c� c � � . � � � O . O � �=r1 P S � 'a c D Z O D . , . r , T m m � � � - " . 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