HomeMy WebLinkAbout0783A WORKERS•�oM�NSAT�oNOE��ARAT�oN � � . ,App�ICATION FOR PLUMBING PERMIT ��77
I hereby,aifirm�ho�I have a certifiwie oi consent�o self in- �A��A�°�8�. , n
svre,ora certifim�e of Worke�s'Compensation Insuronce,or o CE 817(REv.9ie6) � � ' � .j j
"cer,7ificd copy�hereof(Sea 3800,Lob.C.) ' � � ' - LJ
Policy NoZ�WCOOSO�iJ@�„�`iATIONWIDE � • COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certified copy is he�eby fumfshed.� � _ LOT PLAN 4 � TRACT�' 42578
� FOR APFUCANT TO Flll W(PRINT OR NPE) BUROiNG
Cartified topy is filed with the county building inipettion nooRess 916 SOUTH WYNNEWOOD DRIVE
deporlment, NUMBER FI%TURE OR ITEM (d FEE .
i°�"uTr DIAMOND BAR
Dote�J—i—HH qppli[onNEW PLUMBING. 3- �"/ATERCLOSET(TOiLET) G LH NEAREST
� CERTIFICATE OF EXEMPTION FROM WORKER$' Z BATH TUB � . 12 CROSS ST. GRAND AVE�. �
� � � COMPFNSATION INSURANCE � � z , SHOw�ER 12 owNER .,-gRAMALEA LIMITED _. '
(Thfs sMion naod�rof 6o cemplotod if Ihe work fnvolved by
ehe permil H for ona hundred dollara(5100)or Isss.) 5 IAVATORY � � 3O ooRE55 3151 AIRWAY AVE. SUITE N
I certify Ihal in the performonce of the work for which lhis per- SINK
mir is iuuad,I shall not employ any person in ony monr+er so 6 ��T'COSTA MESA TEI.NO$SO—LOOL
os fo become s�bjecf 10 the Workers'Compensafian Laws.� DiSHWASHER
Do"ie ' ' Applicane ' 1 CIOTHES WASHER 6 eoNreaeTe�EW PLUMBING CONTRACTORS, INC. . _
" �+CE TO�APPLICANT:IF,ofter moking fhis Cerlifimte of Ez• ADDRE55� 21[�1 $. DUPONT DRIVE
A�on,you shobid become sobject l01he Workers'Compen• SWIMMING POOL RECEPTOR
solion provisians of fhe Labor Code,you must forlhwilh comp- . (qWN SPRINKLER SYSTEM �'T�ANAHEIM; TE`."0 937-3972
ly wiih such provisions or this permil shpll be deemed revok- STATE uC.
ed. � , �� � � , 1 WATER HEA7ER 6 ucen,se No426109 CLA55 C-36 .
IICENSED CONTRACTORS DECLARATION oiSieiGi No. veocE55ED Br
I hareb ofiirm iha�I om I�censed�nder GAS SYSTEM OUTLETS �
y provisions of Chopter 1 6 6 �
9(commencing with Seciion 7000)of Division 3bf the Business 1 OUTLETS OVER . 1 5�
�ae d Professions Code,and my license is in full force and ef-� 5 aez SvSiEM fINAL V IDATiON a
� DATE �`�y� 0 .
License Number�4Z6LO9 Lic,Gloss C-3fi
FINAL I V
NEW PLUMBING 8-31=88 ev °C
'�Contrador Oare . �� O
F-
� I om exempl under Sec. . , yVj
��lBJ/1
B.BP.C.for�h�s reason - pian check fee ' � � Z
� � . , , , O°�e' - �PWMBING PERMIT ISSUING iEE$ LO SO ��• � �� .
Signmu�e � � � TOTAL FEE � ° � � C«G�
114 00
� � SINGLE FAMILY � -
' HOME OWNER�BUILDER DECLARATION P�an check opplitant � . s n � � LL Q Q�
I hareby ofiirm thm I am e:empt from ihe Conuactor's License Nome - �D E�� O—H S
!.�or rhe following reason�Section 7031.5, Business and
ssions Code): � - Add�ess • . � �
� I,as owner of the p�operty,�will do ihe wo�k ond Ihe Cily Tel.No. . - ,
structure is not in�ended or ofiered for sole(Sec�ion 7044,
8usiness and Professions Code�. � ' � � � ► -. � � �
� ..CONSTRUCTION LENDING AGENCY - . ' ' �
I hereby affirm thot there is a mnstruction lending ogency for � ' � .
Ihe periormonce of Ihe work for whith this permil is issued �� � � � �- � � ' � � � � � �
(Sec.3097,Civ.C.j. . . , -
Lender's Nome � � � ,
- i� . . . . . . . �
Lendar's Address � � � ; �
I cer�ify thof I hove read this application and sfote Ihal the , �- � �, ' �� � . '
obove information is torrett.I ag�ee to comply with all County - , -
�ordinances and S�ate laws reguloting Plumbing,and hareby " ' � ' -
.authorize represeNaiives af this Couniy to enter upon ihe . � �
o ve-m Nioned proper�y for inspedio purposes � � - -
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Parmit�ee Dote
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