HomeMy WebLinkAbout0765A 'WORKERS'COMPENSATION DECLARATION � APP`ICATION FOR PLUMBING PERMI�
I hereby„aftirm lhot I hove o certificate of consent io seli in- pA���ADPW 4!87- ' �
aure,or o certificate of Workers'Compensation insorante,or o CE Bfl(REV.�Bie6} - � ' � : �
cerufied copy thereof(Sec.3800,Lob.C.) . � � �
Pdlky No.Z�WC005047cf),98(�n;NATIONWIDE COUN7Y OF LOS ANGELES DEPT.OF PUBUC WORKS
LOT PLAN:25 TRACT:42578
� Certified copy is hereby fumished. � � . �
� fOR APPIICANT TO Flll IN(PRINT OR TYDE) BUIL�ING .
I=7 Certified mpy is filed with the county building inspection ' aDoaE55 Ql+ZQZ �ST BRYN�E�THYN WAI'
U� deparlmeM. . � NUMBER . . FIXTURE OR ITEM �+ FEE �
LOCALITY DIAMOND BAR � �� -
Dare4-1-88 App�iconNEW PLUMBING 3 �'�'ATER CLOSET iT�LLET1 b 18 N�naEST
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 � BAT„TUB 18 CROSS 57. GRAND �AVE. �
� COMPENSATION INSURANCE � 1 � SHowee� ( ow"ER�' gg�LEA LIMITED:� � .
(This s�Nfan n��d nm b�complNad i{th�wo'k Invofv�d by ���
fh�p�rmN Is fo�on�Aundnd dollan(5100)or I�s�.) � 4 invaroav � Z!i aoosess 3151 AIRWAY AVE. SUITE N
, I cenify thoi in the performance of ihe work(or which this pen 9NK : �
mi�is issoed,I shall not employ any person in any manner so �2 12 arv � COSTA MESA TEL.NO.SSO�lOOl
os fo become subjacl to the Workere'Compensalion Laws. DISHWASHER
6 coNrancrolrTEW PLUMBING CONTRACTORS, INC
Dale ' Applicant 1 CLOTHES WASHER b ADDRE55
J"'^TICE TO APPLICANT:I(,aher moking�ihis Cerfifim�e of Ex- � � Ll�il S. DUPONT DRIVE
� Jion,yoo shou�d bewme subjaU+o the Workers'Compen• SWIMMIN6 POOI RECEPTOR
sarion rovisions of�he Labor Code, oo must forthwith com � ��T� ANAHEIM rEi."o.937-3972
P Y P' IAWN SVRINKIER SYSTEM
ty wi�h such provistons or this permit shall be deemed revok- SiarE � u[. -
ed. � � � � 1 . WATER HEAiER 6 ucENSE No.426109 G1A55 C-36 �
. � IICENSED CONTRACTORS DECIARATION DiSiRiCr NO. PaocE55E0 BY
� I hereby affirm�ha�I am licensed under piovisions of Chop�er GAS SVSTEM 6 OUTlETS 6 �
9(commencing wi�h SeUion 7000)of Division 3 0l the Bosiness Ol17LET5 OVER
� ��d Prafessions Code,ond my license is in 1u11 force and ef- 1 5 PER SYSTEM 1 50 FINAL ��� ALIDATION a
DATE 0
license Number 426109� Lic.Class G—�6 .
U ,
FINAL
Cono-acro� I3EW PLUMBING Da�e 8-31-88 sv :O 7 G 5 l� O
QI om exemp�under Sec. � . . $r• o ° • �Jr w
a
s.av.c.fo��h�:�easo� Plan check fee , f • 1 1 4 0 0 z
� � ' Dote: PWMBING PERMI7155UING FEE S � i 1 � �.G a�
� S�gna�we - � � TOTAL FEE � 114 00
' SINGLE FAMILY � O E � O—Ci B
� � � � HOME OWNER-BUIIDER DECIARATION Plan�check applicant . . .
I hereby offirm�hat I om exempt from the Confracror's License Name � - � .
r"'`.for 1he followinq reason(Seciian 7031.5,Business ond � � � �
. essions Code): Address � . , �
� 1,as owner of ihe properly,will do ihe work and Ihe City � Tel.Na � .
�� � structure is not in�ended or offered far sale(Seciion 7044, _
� Business and Professions.Code�. � � � � . ,
' . � CONSTRUCTION LENDING AGENCY � � � � - � � � � � � .
1 hereby affirm that there is a construction landing agenry for � .
, ihe performance of the work for which�his permi�is issued � � . . �
. (Sec.3097,Civ.C.). . � . . �
• Lender's Name � '
� Lender's Address � � . �
I cerlify Ihat I hove reod�his opplicatlon and siate Iha�the � -
� obove iniorma�ion is correct.I agree�o comply with all County . - ► . . . '
ordinances and State lows reguto+ing Plumbing,and hereby . � ' - � �
authorize represenratives of Ihis County la enter upon the , , � ,
. o4p:e-m��ed proPerfy for inspecY n purpose� � � . � . . . .
� � SEE REYERSE FOR EXPLANATORY LANGUAGE
� Signplure of Perminee • Date � � .
APPROVALS DP7E INSPECtOR'SSI�NATURE � � � INSPECTOR'S NOTES . � ��OWNER BUIIDER DECLARAjION ,
UNDERSLABWOAK . , I h6fBby BMIRR th91 I Y111 exampt hom the Contrectafs
ROUGH PLUMBING UC608B Ldw 10f tIW ft1110W1iq �66800 (S@CfIOR JQ�1.S,
cas a�aiNc � �� � - Business and P�ofessbns Code). Any clty or counfy
` "- whlch requires a permtt ta construct alter, improva,
cns veNT ' demollsh or repalr any structure,prlor fo Its tssuance,
Hor warea r+enTeA also requfres the applicant lor such permlt to file a slgned
P�oMeiNc Fixruaes stafement ihat he fs llcensed pursuant to the provisfons
ansresr ,� otfheContractor'sLkenseLawfChapte�9�commencing
wfth SeCtion 7000)oi Division 3 ot 1he Business and Pro-
UTILITV CO.NOTIFiE� /essions Code)or thai he Is exempi the�efrom and the
6asis for the alleged exempt/on.Any vtolatio�ot Sectlon
703L5 by any appficant/or a permlt sub/ects the appli-
FiNa� __.._ -�'ntar on��onE � � � - . c8nt to a.civ!!penalty of rrot mo�e than live hundred
, dollars(5500)•.
iNousrpra�- . � � . - � ' ❑I,as ownor ot the propwty wlll do fha work,anq the
YfASTE APPflOVAL � � 6tNCtt7(@ IS ROt 1lliBtl�W O��G!@d�Of 887e.
(Sec.7044.8uslness antl Professlons Cotle:The Contrac-
- � ror'sllcenseLawdoesnotappfYtoanawnerolAro�rty
. - . � . �, . , -: whoEulfdsorfmprovesthereon,antlwhodoessuc rk
_. hlmseff provfded that such lmprovements are not Im�ntl-
- ed o�ol�ered for sale.!!,however,the buUding or lm-
� • provement Is sold withln one year of completion, !he
owner•builder will have the burden o/proving thaf he did
not bu!!d or lmprove for the purpo8e ol sale.):
- _ 1 am exempt under 3ec.
B 8 P.C.for thle reason
__ __
Date
Owne►
1NSPECTOR'S NOTES - _