HomeMy WebLinkAbout0781A � - 1NORKERs�oMPENSAT�oNOE«ARAT�oN � APPUCATION FOR PLUMBING PERMIT �} �
I here6y,affirm fhot I have o certifim�e oi consenl�o self in- '�A��A�ai67 �
sure,or a certiticote of Workeri Compansation Insurance,or a CE Bq(REV.8/86) � - . . � . ��
�cerlified copy thereoi(Sac.3800,Lab;C.� . - � . � ' - � � ,
volicy No.�3WC005047��yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certifiad copy is hereby furnished. � . 2 PI' .
FOR APPLICANT TO FIIL IN(PRINi OR TYPE) BU1lD1NG
� Certified copy is iiled wilh the munty building inspecfion ADDRE55
, deportm0nt. NUM6EF FI%TURE OR ITEM (d FEE ��A`�T�
Data9-1-88- Applican�EW PLUMBING 3 . W/+TERClOSET(TOILET) � G 18 NEAREST DIAMOND BAR
- ' CERTIFICATE OF EXEMPTION FROM WORKERS' � 2 BATH T�g 1 Z CROSS ST. GRAND AVE. � - �
'� �'� COMPENSATION INSURANCE Z SHOWER � 12 ow"ER. gRAMALEA LIMITED ��
(Thb�s�ction nsed net 6e complef�d if tha work involvad by Mqii
fha p�rmil Is for ons hundr�d dollar�(SI00)or loss.) 5 . uvnroRv � . .30 /o�ReSS 31$1 AIRWAY AVE. � $UITE Zd .
I ter�ify thol in the performonce oi ihe work far which Ihis per- SINK
m(t is issued,I.shall�no�employ any person in any rtmonner so 6 ��T�COSTA MESA � TE��"o.g50-1001 ,
os�o become subject to Ihe Workers'Compenwlion Laws. o�5HwA5HER � '
, . 1 6 coNTRncro�EW PLUMBING CONTRACTORS INC.
Dote ' AppliConl ' � ' 1 CLOTHES WASHER (7
A�DRESS
ICE 10 APPLICAN7:If,ofter�making�his Car�ificore of Ex. � Ll.�il S. DUPONT DRIVE
� ��ion; ou shouid become sub'eci to�he Workeri Com n- SWIMMING POOI RECEPTOR
v i a� an��EIM TE� "0 937-3972
��w�ion plovisions of the Lobor Code,yoo most forrhwifh comp- _ . �qWN SaeiNKIER SvSTEM
ly wi�h such provisions or this permil sholl be deemad revok- STATE tIC. �
ed. ,� - "- - 1 WATER HEATER 6 UCENSE NO. 1 � C1A55 C— 6
�. . - LICENSED CONTRAC70RS DECLARATION - DRTRiR N4� PaD[ESSED BY
GAS SYSTEM OUILETS �
I hereby af(irm�hat I am licensad unde�provisions ot Chapter. 1 � B 6 .
I 9(commencing with Section 7000)oi Div�sion 3 oF the Business . 1 OU7tE15 O�FR 1 5� ,
and Pro�955ions Code,ond my license is in(ull for[e and ef- 5 PER SYSTEM FINAL �/�� ALIDATION O
fect. DATE f
'L+cense N�mber G2fi109 ���,��ou C-36 V
FINAL
Gontroctor NEW PLUMBING po1e 5-31—E8 BY �� O
F„
� �o�a, A
I am ezempt under Sec. ! a
e.BP.C.for�h�s reoson plan check fee , ��• ' � • �J 2
•� - Da�e: � � � p�UMBING PERMIT ISSUING FEE S lO SO I � , , �U�
� $ignolure . .1 1 A r.n-'- .
-� . � . TOTAI FEE i l/y OO '
, . . SINGLE Fi.MfLY p�o��heck applicant
HOME OWNER-BUILDER DECLARATION � � O E.� O'F3 H '
I h�ereby affirm ihot 1 om exempf from the Contrac�or's License Nome � � � � �
\ior the following reason{Section 7031.5,B�siness ond �
_lessions Cade): . Address
� 1,os owner of the propeity,will do ihe work ond the ���Y. 7e1.No. .
struclure is nol infended or offered for sale�Seclion 7044, , . .
. Business and Professions Code). , � ' ► �� �� �
CONSTRUCTION IEN�ING AGENCY . � - � � � � � � '
I hereby�affirm rhat rhere is a cansrruction lending agency for �� - �
ihe performance of the work for which this permit is issued ' " ' - . . " � -
(Sac.3097,Civ.C.). • . �
Lender's Name � • �
lender's Address � . '
I certify thot I have rood this opplicorian and state that�he � � �- � � � �� ► ' ' � �
above informotion Is correct I agree to comply wi�h ail CouNy -
ordinances and Slate laws reguln�ing Plumbing,and hareby ' � � -
authorfza represantativas of rhis Counly lo enler upon the ' � ,
ob ve-m tioned proparty for inspectio pwposes. � �' . . ,
� ��;�� ��_� SEE REVEItSE FOR EXPLANATORY LANGUAGE
�.f
Signoture of Perminee Da1e� � ,
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