HomeMy WebLinkAbout0782A ' � WORKERS'COMPENSATIONDECLARATION APPLICAfiON FOR PLUMBING PERMIT . {� �
� I heraby,offirm ihat I have a certiticate of cansenl fo self in- 7��,A PW��87� �
sure,or o certifimle of Workers'Compenwtion Insuronce,or o fE el7(REV.e/86) �� . � ��
"cer,li(ied copy ihe�eof($ec.3800,Lab.C.� - _ , -
Policy No.Z�WC005047�n�NAlIONWT__ I��_ COUNTY OF LOS ANGELES pEPT.OF PUBLIC WORKS
LOT PLAN:25 :.• TRACT:42578
� Certified copy is hereby♦urnished. �, BU�IDiNG
FOR APPLICJ+NT TO Flll IN(PRINT OR TYPE)
� Certified mpy is filed wiih the coonry bu�lding inspecuon nooae55 912 SOUTH WYNNEWOOD DRIVE
deportrrient. - �'-. , NUMBER FIXTURE OR ITEM .@ FFE �«ALiTY
WATER ClOSET(TOILET) DIAMOND BAR
Dote9-1—RR ApplkanNEW PLI7MBING 6 18 N¢aaES� • .
BA1H TUB ' CROSS ST. GRAND AVE.
CERTIFICATE OF FXEAAPTION FROM WORKERS'� � I.H
� � COMPENSATION INSURANCE 1 SHOWER � � - 6 OWNER gg�LEA LIMITED �
(This s�ctton nead not b�completed if tba work involved by p,yii
}h�p�rmil ts for on�Aundred dollon(3100)or lesl.J ' L4VATORY � 24 ao0aE55 31$1 AIRWAY AVE. SUITE N
I certify that in the pe�formonce of Ihe work for which this per- . SiNK . � "
mi�is issued,I shall not empioy any person in any monner so ].2 ��T� COSTA MESA 'E�."o.g50-1001 �
os ro batome subjett to ihe Workers'Compensalion Laws. DISHWASHER oNEW PLUMBING CONTRACTORS� INC.
' CONTRACT
Dafe Applicont � 1 CLOTHFS WaSHER 6 qDORE55
' �ICE TO APPLICAN7:If,after making Ihis Certificote of Ez• SwiMMING POOL RECE7TOR 2141 5. DUPONT DRIVE
tion,you should becoine subjeci ro the Workers'Compen-' . CiTY TEI.NO.
Sation provisions o(1he Lobor Code,you must lorthwith mmp- (AWN SPRINKLER SYS7EM � ANAHEIM 937-3972
ly with such provisions or�his permil sholl be deemed revok- S7AiE LiC. �
ed. � � WAtER HEATER UCENSE NO. [LASS C—
� � LICENSED CONTRACTORS DECIARATION � 6 DISTRIQ NO. PROCESSED Bv
1 hereby affi�m Ihot l om licensed under provisions of Chapfe� GAS SYSTEM OUTLETS
9([ommencing wilh Seclion 7000)of Division 3 of the Business OUTLETS OVER �
fe�,Pro(ess�ons Code,and my license is in full force and ef- 1 5 7eR SYStErn 1 $� FINAL �/��/r� VA DATION : a
DATE � �
License Number���LOB � ���•Closs C-46 � �
FINAL V
Contrac�or NEW PLUMBING Dme 8-31-88 BY �`�'�� ¢
O
� I am exempt under Sea � `��7�'2 n W
a.aP.c.to�ih�s�easo� Plan check fee �� � ° � °5 �'
z
" � - Da�e: � . PLUMBING PERMIT ISSUING FEE 5 � "� � �O O
SignaNre � TOTAL FEE � • L, ('�T
114 00 • 1 i . C„�
- ' SINGLE PAMILY plan check oppliwnt
HOME OWNER-BUIlOER CECLARATION � � (J�� O—p 8 -
I hereby offirm tha�I om e.empt from the Coniroctor's license Nome � � � • � �
�for fhe following reason(Section 7031.5, Business ond � � -
_ ssions Code): Address .
I � I,os owner of fhe propnty,will do ihe work and ihe _City �� Tel.No.
sirucrure�s not intended or offered for sale(Section 7D44,
8usiness and Professions Code�. ►
��. ��� � CONSTRUCTION LEN�ING AGENCY . ' � - . �
I hereby a(firm ihoi ihere is a tons�ruction lending agency for ' �
ihe perPormance of ihe work(or which ihis permit is issued " ' " "" �
(Sec.3097.Civ.C.). . '
Lender's Name - ' .
Lender's Address ' � . �
I wrrify ihot I have read this applimtion ond s�ote that ihe � � � ' .
obove informofion is conect I agree fo comply wifh oll Coun�y ' ' . . _ � .
ordinances ond S+are laws regulating Plumbing.ond hereby ' � � � -
authorize represenlalives of this Coun�y to enter upon tha �
o' ve-m ioned property for inspeUion pmpo5e,�� - �� - . .
� SEE REVERSE FOR EXPLANATORY LANGUAGE
_ gnalure of Permitlee Date .
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