HomeMy WebLinkAbout0769A ' WORKFRS'COMPENSATION DECIARATION qppl,IGATION F4R PLUMBING PERMI'f
I here6y,,dfirm rhat I have a cen;fiwre of wnsenr ro self in• '�'A�2jA Pw 4i8� , f�j
sure,ar o certificpte of Wo�kers'Compensarion Insuronce,or o CE eq(REV.e/86) . . ' j j
,cartified copy the*eof(Sec.�3800,1a6:�C.) � � � LJ
Pou<y No.Z3WCOD5047�p(Abn�19ATIDNWIDE COUNTY Qf LOS ANGElES DEPT.OF PUBI�C WORKS .
� Ce�t�Sied copy is he�eby fumished., LOTl PLAN:25 TRACT:42578
� fOR APPLICANT TO FILI 1N(PRINi OR TYPE) BUIIDING
� Ce�lified topy is tiled with the counly building inspection ADDRE55 T N A�YN wE�Y
clepa�tmo��. . , NUMBER fl%TURE OR ITEM � FEE �OCAIITY
- WAiER ClOSET(TOLLET) DIAMOND BAR .
Da�eq-1—RS Applico�NEW PLIIMBING 6 18 �Ros955i. GRAND AVE..
� - CERTIFICATE OF EXEMPTfON fROM WORKERS' 3 BAiH TUB i$
� COMPENSA710N INSURANCE � 1 SHOwFR� � 6 . OWNER B�LEA�I,IMITED -
� (16b ioNion nMd noi 6a compl�i�d H ih�work�nvo�r�d by , ��i
/h�p�rmit It#o�on�hundr�d dollon(3100)or I�ss.) 4- wvntor.v - 2(+ A�DRE55 3151 AIRWAY AVE. SUITE N
. 1 certify that in tha performance of the work for which this per- SiNK
mit ts issued,I sholl nor employ ony person 7n any manner so 12 ��TY COSTA MESA TEI.NO.sSO—IOO1
os fo become su6jacl lo the Workers'Gompensotion Lows. OISNWASHER - �
coNTancTcNEW PLllMBING CONTRACTORS, INC.
Dota � � Applicant ' � 1 CIOTHES WASHER - � 6 .
f�710E TO APPLICANT:li,after moking rhls Cerriflcme of Ex- AO�RE55 2141 S. DUPONT DRIVE
! 'Iion, ou should become sub'ect ro the Workers'Com en- SWIN�NWG POOI kKEPtOR
Y � P CITY TEL.NO.
s,.�ion provisions ol the Labor Code,you mysf farihwifh romp- �.4WN 57RINKLER SYSTFM . ��EIM 937-3972
ly wifh svcb provisions or Ihis permit shall 6e daemed revok- STATE . ttG.
.ed.' � . . WATERHEAiER LICENSENO./j2()lO9 CLASS C-36
�� �UCENSED CONTRACTORS DECLARATION ,� 6 O�SiR�Ci NO. ' rROCE55ED BY
I here6y affirm thot 1 om licensed under provisions of Chaprer GAS SvSTEM Ou7iE75 6 �
. 9(commencing wiih 5eUion 7000)of Division 3 oi the Bvsiness DUiIETS oVER 1 5� .
and Professions Code,ond my license is in full 4orce and el- 1 5 PER SYS7EM FINAL VALIDATION }
IecL . ' DATE���� a'
License Number 4?h109 �Lic.Class r—�b U
FINAL
Contractor NEW PLUMBING ' Dote 8-31-88 BY a
O
F-
� I om exemp�under Sea " �O���l A W
. 6.8P.C.for rhb reason • • ` °� � a
Plan check fee ` $'� z
� Oole: �pWM81NG PERMIT ISSUtNG FEE S � � •� � �,O� �
Signaiore _ - � � TOTAL FEE 11(+ 00 . • •� � L;,(;'U�,
� '� � SINGIE FAhhILY Poon chack apPlimnt
. HOME OWNER-BUILDER DECLARATION � � O�.�G"�H
I here6y offirm Ihot I om eaempi from 1he Comroctor's License Name �� � ' - � �
�far the follawing reason(Section 7031.5,Business ond � �
essians Code): � Addrass - � � � �
, Q I;as owner of the property,will do ihe work ond�he City . Tel.No. � ,
, � struc�ureisnorintendedorofferedforsale(Section7044, . ,
� Business and Professions Code). � '
- CONSTRUCTION IENDING AGENCY � � � � � . �
� i here6y offirm Ihat there is a consfrucfion lending agency for � �
tfie performonce of the work for which�lhis permit is issoed ; . � - � � �
� �(Sec.3097,Civ.C.). _ . . -
� Lenderi Name � �
� Lender's Address � �
� 1 ce��ify fhot I hove read Ihis opplimtion and stafa thm the . "
above information is correU.1 ogree to compiy wifh all Counry � ► ' �
ordinoncas and Stole iows rogutating Plum6ing,and hereby - �_ �
' authorize represenlotivas of this County to aNar upon tfie .
� o e-me tioned properry Sor inspecti purpose. - � . . .
� ,�, SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signoture of Permittee - Da�e � � - . � .
APPROVALS DAiE � INSPEC70R'SSIGNATUfiE �NSPECTOR'S NOTES � � �OWNER BUILDER QECLApAT►ON .� .
UNDERSLABWORN ' ' -� � . � � � . . � h9t9bY 4�1iM1 fhBt I BT B%61TPt flOffl�'th8 COt1tf9ClOY8
ROUGH PLUM8ING � � �� � �CBOlB LiW ta tha fW�owlnp reaeon{Section.703J.5.
GnSPIGING 7� � . � - � - �-�� � � . . .. _.. - - Business antl Pro/essbns Code). Any cJty or county
whlCh reqoires a permit to Con5lrucL alter. lmprove.
cns veNT. � � . - - � . � _ . . demolisb or repair any siruciure,prior to its issuance,
HOT wnreA nen'rea afso�equires the applica�t forsuch peimit to(!le a signed
awueiN�Fttruaes � � � � � � . � � statement tAat he is licensatl pursuaot to the provrsions
of the COntrRClor's License Law(Chapter 9(commencing
cns resr wlth Section 7000)of Oivision 3 07 the Buslness and Pro-
utizirr co.NOT+Fieo - -� - lessiorrs CoUe)or thaf he is exempi there�rom and the
. . . . . . . - � -� ..�basis io�fhe allegEd oxemptfon.Any v/olation ot Section
7031.5 by aoy applkanr tor a permit sub�ects rhe appli-
FINAL �„Ee.on��onl �� - � � � � � - ; c3nt to a clWf penafty ot nof mae than five hund�ed
dollars($S00J.: .
iNousTaiA� . . . . ' . . . '�.l 1,se owner ot the praperty wi11 tlo the work.antl�the
WASTEAPPROVAL . lM1CfUfBiatl0tif12911tl6dO�Of�6f9GfOfS810.
__(Sec.7044,BusinessandProfesslonsCode 7neContrac-
- for's Ucense Law tloes not appfy fo an owner of proparty
� , . . . . . . � . � who 6uilds or improves tbereon,and who d0es suct k
, .. : �. _ • -� himself provided that such improvements are not 1n�,,.,d-
ed or olfered tor sale.7f,however,the building or fm-
� � -- - - � ��- � - - � � �� provement!s soltl within onB year of completion, the
� , . . - � . - � owner-builtler wilf have tl�e burtlen of proving that he did
nof buNd or improve(or the purpose of sale.) �
• _ I am exempt under Sec. :
B 8 P.Q for thls resaon
Date .
Owner
INSPECTOA'S NOTES
• i