HomeMy WebLinkAbout0773A ' WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT
I hereby,offirm�hat.l hove a certificaie of consent to self in- ��yA�jA�4ie� y� '
.sure,or o te�lifi[o1e of Workers'Compensafion Insuronce,ora -�E BV(REV.8/86)- . , I I �
certified copy rhereof(Sec.3800,La6.C.) � LJ
FdYicy No.73WC005047����NATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PU6UC WORKS -
� Certified copy is hereby furnished. � 42 $
FOR AFPIICANT TO FIIL IN�PRINT OR TYPE) BUILDING
� Certified copy is iiled with the county b�ilding inspec�ion � A�pRE55 19 SOUTH WYNNEWOOD DRIVE
daporfinenl, � Nl1MBER FIXTURE OR I7EM (i FEE
LOCAl1TY DIAMOND BAR
DateI-1—SH � Applimn�dEW PLUMBING 3 wahe C�oSeT(roi�er� 6 18 NEAREST
BATH TUB CRO55 ST. GRAND AVE.`,
, ,. CERTIPICATE OF�EXEMPTION FROM WORKERS' � � Z • lz
COMPENSATION INSURANCE 2 SHOWER � � �12 OWnIER gg�LEA LIMITED �
(This section nssd not Ee eomplet�d ti�ha work tnvolv.d by . r„V ii
the permk��For on�hundred dollars(SI00)or le�s.) 'S LAVATORY � ''jO nooaess � 3151 AIRWAY AVE. SUITE N
I certify Ihot in 1he periormance oi the work for which this per- SiNK �
mit is issued,I sholl nor employ ony person in ony monner so ��T�COSTA MESA TEL.NO.$SO—IOO1
os to become su6jeU io Ihe Workers'Compensafion Laws. DISHWASHER �
. 6 coNrRncro�EW PLUMSING CONTRACTORS INC.
Date Applicont ' ' 1 CLOTHES WASHER 6 �
P'^IICE TO AP7LICANT:1(,after making�his Certifico�e�of Ex- . ADORE55 21 1 . DUPONT DRIVE
,' }�ion,you should become subjed ro�he Workers'Compen- SWIMMING POOL RECE7tOR .
'a.... n - . . CITY � iEL.NO.
6 provisions of the lo6or Code,you musi forthwifh comp- �qWN SPeiNKLER SVSTEM ANAHEIM 937-3972
ly wi�h such provisions or this permii shall be deemed revok- 57niE uC.
ed. - � � � � � �. � 1 WATER HEATER 6 UCENSE NO. CLA55 —
� LICENSED CONTRACTORS DECIARAiION CiSTRiCi n0� PROCESSE�BY
I here6y offirm Ihat I am licensed under provisi0ns of Chopier GAS SYSTEM . 6 OUTIEtS fj O
9(commencing wilh SeUion 7000)of Division 3 af the Business OUTLETS OVER
and Professions Code,and my license is in full force and et- 1 5 PER SYSTEM. 1 50 FINAL AIIDATION �"
�ect.- 426109 ' ' � C-36 oAie ��(9/�/r O
License Number Lic.Closs , V
FINAL � �
Conrrador NEW PLUMBING pa�e 8-31-88 BY p
, . f-
� I om exemp�under Sec. <O 7 7�J A W
a
B.BP.c.tor�h�s reoson Plan check fee ► #' ' ' ' °5 z
Date: � p�UMBING PERMIT ISSUING FEE S
io so i • iiaao
Signoture � - TOiAL FEE
" SINGLE FAMILY 114 OO • s � ��(i �i��
� HOME OWNER-BUILDER DECLARATION Plan check opplitant .
I hereby offirm tho�I am exempt from�he Contrac�or's license Name � _ , � . �S�� O—H,H�
'�w for the Foilowing reason�Section 7031.5,Business ond � � '
�fessions Code): Address �
� I,os owner of the properfy,will do the work and Ihe ���Y Tel.No. '
struUure is nof inlended oroffered for sale'�Seclion 7044, . . . . � , ,
Bosiness and Professions Code). '. � � ��
.GONSTRUCTION tENDING AGENCY � � � � - � - ' � ►
I hereby offirm thm ihere is a consMuction lending ogency for � _ ,
the per/ormance of the work for which ihis peimit is issued ;' � . -� � ' ' " �
(Sec.3D97.Civ.C.J. � � ',
Lender's Name � �
Lender's Address � ' �
I certify thot I have read this application and stale that fhe � � - - � ► � - �
above information is torred.I ogree 10 tomply wilh all County � .
ordinontes and Stofe lows�egulaling Plumbing,and hereby � ' � � �
ou�horize represenmiives of this County to en�er upon rhe . .
o ve•m tioned property for inspecti n pu,po5qs.�,/ ��� �
I� Y SEE REVERSE FOR EXPLANATORY LANGUAGE
I� Signofure of Permilfee Dale� � ,
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