HomeMy WebLinkAbout0785A WORKERS•�oMPENSAT�oN oE«ARAT�oN � App�ICATION F4R PLUMBING PERMIT�
I herebyj affirm ihat I hove�a cerfiiicate oF consen�10 self in- �26 Daw aie7 � f1
sure,or C cerlificafe of Warkers'Com ensation Insurance,or o �6Ad67A . �
P � CE B17 REV.B/80) � I I �
'ceflified copy thereof(Sec.3800,Lab.C.) ,, - - � - Ll
Pdlicy No.73WC00504,�Q,�(*yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
'� Certified copy is hereby furnished. ._ L�T PI+.�:24� � TRACT: 42578 �
FOR APPLIG4NT TO FILL IN(PRINT OR TY7E� BUILDING
� Certified copy is filedwith the county buiiding inspection nooRe55932 SOUTH �'TITTEWOODDRIVE
deparimenl. NUM9ER FIXTURE OR�ITEM (d_ FEE
LOCALITY
Oale9-1-88- apPl�co�rNEW PLUMBING� 3 WATERCLOSET�TORE7J (1 18 NEARESi
' , CERTIfICATE Of EREMPTION FROM WORKER$' - z BA7H TUB � LZ CROSS 5T. �D AVE.
COMPENSATION INSURANCE . � OWtv[z MI � �
1 $HOWER . - 6 .
(Thia seMlen n�od�nef b�compl�t�d if}hs work invelv�d by
�ho pvrmit la lor ono hundrsd dollan(SI00)or I�si.J � IAVATORV 2[y DDeESS 3151 AIRWAY AVE. SUITE N
I certify that in the performance oi tha work for whith this per- SINK
mit is issued,I sholl not employ ony person in ony monner so 2 � - ],Z � CITY TEL.NO.
COSTA MESA 850-1001
as to become eubjett to the Workers'Compensalion Laws. �ISHWASHER
• 6 coNrancTo�EW PLUMBING CONTRACTORS INC
Dote - � Appiicant � 1 CLOTHES WASHER 6 .
ADDRE55
CE TO APPIICANT:If,afler moking�ihis Cenifimre of Ea• � � � 21 1 . D PONT DRIVE
� tion,you should become subject lo ihe Workeri Compen- SWIMM�IJG POO�RECEP70R
CIiY TEL NO.
sofion pravisions of�he LoIJOr COde,you mu511or7hwith comp- . �AWN SPRINKIER SVSTEM ANAHEIM 937-3972
ly with such provisions or this permii shall be deemed�evok- STnTE LIC.
ed. � � 1 WATER HEATER 6 uCENSE NO. � CtA55 — �
. LICENSED CONTRACTORS DECLARATION DiSTRiCT NO. PROCE55ED BY
I hereb afFirm Ihat I am licensed unde� GAS SYSTEM OUTIETS /
y provisions of Chap�er 1 6 6 f(7
9(commencing wi�h Secfion 7000)of Oivision 3 of�he Business OUTLE75 OVER
ond Professions Code,ond my license is in full force and ef- 5 PER SYSTEM 1 5� DA E� �//►� ATION a
�e�,. �o/�9
License Number 426I09 ' Lic.Closs C-36 �
. . . , � fINAL - V
Co�rracior NEW PLUMBING Dare g-3I—BH BY /�ct/�!/ �
O
❑ ~
I om e.empt under Sec. V
. ?07�5A a
B.BP.C.for this reason � , . y
Plan check fee Z
Date:� PLUMBING PERMIT 155U�NG FEE 5 f� � � � �5
Signafure TOTAL FEE � � • � ��Q�
SINGLE fAMILY LOH OO
HOME OWNER-BUILDER DECIARAT�ON P�o^check opplicom . �. . • ° � C'��Q O�J
I Foreby a(firm that I om eaemp7 trom the ConiroUoi s License Nome G�� C'�U
loi the fallowing reoson(Seci�on 7031.5, Bus�nesz ond
,_, ssiansCode): . Address � � �
� I,os owner of�he property,will do the work ond the �'�Y Tel.No. - �
sfructure is not infended oroifered for 5ole(Se[lion 7044,- . . . -_ . _ �
Business ond Professions Code). . - : ' -. ,
' CONSTRUCTION IENDING AGENCY � � ' " ' �
I hereby affirm that there is a construction lending agency Ior . . � � �
the performonce of the work for which rhis permi�is issued � � �
(Sec.3097,-Civ.C.). �
Lender's Name � � �
I lender's Addiess ,
I certify�hat I hove read ihis applicalion ond sta�e that Ihe " . � �, ' " " ��
nbove intorma�ion is correct.I ogree io comply with oll County " '
oidinances and S�o�e laws regulating Glumbing,ond hereby - ' � �
aulhorize representolives of this County 7o enter upon the �
ob ve-menl' ned properfy for inspection purposes. - �
�� SEE REVERSE FOR EXPLANATORY LANGUAGE /
Signature af Permitfee Date - /'
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