HomeMy WebLinkAbout0772A � '"°RKERS•`°"'PE"S"T'°"°E""R"T'°" � APPLICATION FOR PLUMBING PERMIT �
I hereby;oSfirm thal I have a certifimte of conseM to self in- �'�d Daw aie7� .
sure,or o certifica�e of Workers'Com ensation Insurance,or o 76A66�A . ` , .
P CE 8q(REV.8/B6)
certified copy thereof(Sec.3800,Lab.C.) . ' � .
Pdlicy No.74WC005042Ae�yNATTONW7D�_ COUNTY OF LOS ANGELES DEPT.OF PUBUC WORKS
� Certified mpy is hereby furnished. . T21 PLAN• � � RA T•42578 I
FOR APPLICANT i0 FILL IN�PRINT OR TVPE� BUIIDING
I"1 Certified copy is filed with the courity build�ng inspection .4DDRE55 z Q WYN EWOOD DRIVE
�-�� deporlm0nt. � NUMBER FU(TURE OR ITEM @ fEE �«A��TY
WATER CLOSET(TOILET)
Date Q-1—RR Applican�NRW •TMR N. 1 NEAREST '
CERTIPICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 St. � "
� ` ' COMPENSATION INSURANCE 1 SHOWER � 6 OWNER BRAMALEA LIMITED �
(ihis�acfion n�ad nof ba complotad i4 the work inrolrod by ���
Ihe permlf if Fo�ons hund�sd dollars(5100)or Ie�s.) - LAVATORV � 2 ADDRESS 31$1 AIRWAY AVE. SUITE N
I cerlify Ihat in ihe periormance of the work for whith this per- SiNK
mit is iss�ed,I shall not employ ony person in ony monner so ��T� COSTA MESA TEL.NO.$SO�LOOL
as 10 6emme subject m the Workers'Compensmion Lews. DISHWASHER
coNTenaog�EW PLUMBING CONTRACTORS, INC
Dale � � � Applicam � � �� 1 CLOTHES WASHER � 6 ADDRE55 �
D'^ICE TO APPLICANT:If,affe/making this Ceitificote of Ex-. SWIIMIING POOL RECEPTOR �
on;you should become subject to the Workers'Compen- GiTv tE�.NO.
's.,.� n provisions of the La6or Code,yov most forthwith tomp- LAWN SPRINKLER SYSTEM —
ly with such provislons or this permit shatl be deemed revok- 57aiE tiC.
ed. . � ' � - . WATER HEATER LICENSE NO. CLA55 — .
- UCENSEO CONTRACTORS�ECLARATION . DISTRICT NO, P�OCESSED BV
I herehy affirm�hot I om litensed under provisions of Chopfer GAS SYS7EM OUTLETS /� •
(
9(commencing with Section 7000)of Division 3 ot the Business OUTLETS OVER
ond Proiessions Code,a�d my license is�n f�ll force and ef- 1 5 PER SYSTEM 1 50 FINAL ALIDATION >'
fect. . DATE u �4 I�"R
��26109 a
License Nomber Lic.Class r—�F � O
FINAL V
Contracror NFW PL.L�ING Date R-31—HH . BY �� �
O
H
. � I am eaempt under Sec. � � W
077,2A a
B.BP.C.(or this reason ► z Z
Plan check fee
. Dote: PIUMBING PERMIT ISSUING FEE S �� • • a •S
. Signature � . TOTAL FEE � 114 �� � • � � [J,�n
� $INGLE FAMILY p�a�theck o I canl �� � �� O
� HOME OWNER-BUILOER DECLARAT�ON PP' � � � • � _
I hereby affirm tha�I am ezempt from fhe ConiroUor's t�censa Name �
�for Ihe following reason(SeUion 7031.5,Business and � O E.� O—H S
ssions Code): . � Address . � �
� I,os owner of the proper�y,will do ihe work ond the Ci1y . Tel.No.
svucrure is not inrended or offered for sale(Section 70a4; .
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY � � � '
I hereby affirm tha�there is a tonslruction lending ogency for � � � �
the periormanto of the work ior which Ihis pe�mil is issued ' � � � - � � � '
(Set.3097,Civ.C.). � . . .
lerider's Name
lendar's Address
I ceriify thal I hove reod this application and slote that the �
ohove informalion is torrett.I agree to comply wi�h all Co�nty • ► -
ordinances ond Slate laws reguloting Plumbing,and hereby . • � �' � �
aufho�ize represeNatives of this Coun�y ro en�er vpon rhe - _ � . ,
�Pve m �ioned property for inspec�io pur oses. �•� -� .
:� - SEE REVERSE FOR EXPLANATORY LANGUAGE
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