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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� � , T D� z ~ � �' O D D O C NC D r 41 C N C m'�'' r' � m m � � .0 c� r�„ • D� N y m �O = � . ... O� Z '� L7 � -1 � C � � T � � ' j , O ' -xi m w �{ O . � T � � . , z o � Z � - . ._ .� � tmi� a � C X � „ _ . � m . :�� . � A w o . , � ' . . , :• a V� � : r „ T -D+ Z , ' - *�`t �, rt' . � � � � ~ �^ � _ . . .o m , � -ni � O . , � � . .. , tn . ' y . ' Z . ' C � ' . m . � � . 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