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HomeMy WebLinkAbout1131A 4 WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT - C���7� I hereby,ofRrm�hot I have a certifica�e of mnsen�ro self 76A887A . . . 'inswe,or a certificole oi Workers'Compensotion Insuronce, CE 817(REV.8/88) � ' or a ceriified topy ihereoi(Sec.3800,Lab.C.) � � . . 0���5739 Hig�,�ds Insurance Co COUNTY OF LOS ANGELES DEPT. OP-PU@41C�1KORK3 Cerrified copy is here6y furnishad. - UAltS 436,437,h3$'" FpR APPLfCAN7 TO Fllt IN(VRINT OR TYPE) BUILqNG �( Ceriified copy is filed wilh!he county buildtng inspac- nooRE552291.1 SStOTll NUMBfR FIl(TUREORITEM � FEE ���TM , Diamond Baz . 8��°2��"�'°�matore Plnmbing, ZIIC. WATERCLOSET Porto Grande po�e - ApPli4am 9 6. 54 0 �A�si . . . CERTIFICATE Of EXEMPTION FROM WORKERS' BAiH 7U8 CRO55 SL . COMPENSATION INSURANCE �WER OWNER presley Of Southein Calif ; . (Thi���ctlon nMd no�b�compt�Md tf th�work tnwiv�d by 3 6. 18 �� �` th�permlf i�for om hundnd dollon(s�oo)o.�.ss.) 12 LqyqTORV 72 00 ADDRE55 17791 Mitchell South I certify Ihol in the performance of the work for whith Ihis permif is issued,�shall nof employ any perwn in ony manner �NK c,rv-irvine . . . ,��.,,p, —0 Q — so os to become subjact lo the Workers'Compenwlion laws. DISHWASNER . 18 00 con,rw,croa Amatore Plumbing� Inc. �e epplimnt 3 CLOTHESW.ASNER 6. 18 00 ��u 127 W. State St. ' �..OiICE TO APPUCANT: If, oker making this Certifim�a o� � �`mption, you shou�d become subjed to Iha Workers' SWiMMING VWL RFCEPTOR _ � F'�+pensotion plovisions of the Labor Code,you musl forlh- LAWNSPRINKLERSYS�EM ��ry ontario ���^��986-5878 nc �omply wifh such provisions or this permit shall be STATE lK. �deamed revoked.- - ' � ' WATER NEATER u�Ns�No. 355068 CL455 C-36 - UCENSED CONiRARORS DECLARATION D�SiR�CT MO. 7ROCESSfD BY . I hreby off�rm Hwt I om licensed unde�p�ovisioni of Chapter 9 3 GAS SVSTEM OUttETS (. 1$ Q Q - � �(commencing wi�h Sec�io�7000)of Division 3 of d+e Busfness 3� WTLETS OVER ��j f} �jQ � � Y� ond Professions Code,o�d my license is 7n full fw[e and effect. 5 PER SYStEM FINAL VALIDAT�ON DA7E� O �icense Numbe� 355068 �ic.Closs C-36 � �m�tQre Plumbing, I�r�- 8/26/87 eY� � o ' o�,a�o, � � ❑ o 1 am eaempt under Sec. d � . B.BP.C.for�his reason ► -Z Plan check fee `� � �� A . . ���� PLUMBING PERMIT ISSUING FEE S ZO rJO S�qnaWre � • • • • �5 . . TOTAL FEE ZS5 OO � 1 �28500 � Plan theck applimnt .. . . . .. . SINGLE FAMILY • "2 c�.5.O O� i• _ HOME OWNER-BUILDfR DECIARATION Name �I tiereby offirm that I om e�emp�from the Controctor i License �i Q 2��8�] . �'or!ha lcllowirg fe6i3t1(;sctlon 7031.5,Susiness and Addrens ess�ons Code): City . Tal.No. . . ❑ 1,as owner of fhe properly,will do the work ond ihe strvtlure is no�in�ended or ofiered for sole(Secrion ► � � � � 704�,Business and 7rofessions Code1. CONSTRUCTION LFNDING AGENCY � I hereby affirm�hol Ihxe is a conslruction lending oqe�Cy(or � . . rhe performance of the work for which Ihis permit ia issued � -� - - (Sec.3097.Civ.C.). � - � '� lender's Nome - � ��lender's Address � �I terlify thol I hove�eod this opplicolion aad stale tFrot Ihe � - � � ► above infamorion is correU.I opree lo comply wi�h all Co�ny ordinances ond$tate laws reguloling Plumbing,and hereby . . . � . . . outhorize prcsentati a�F of this Counly to entar upon Ihe � �bove nti ed pqFty for inspeaion purposea. - -y � �� y� SEE REVERSE FOR E7fPLANATORY LANGUAGE a gna r f rminee Do� . . . r• _ , � . _ ... , . .. �z T = c� � = c, c� o � . .. . _ .. .. . -+ ~ U fn fn�C m7 N�" y r � : < v C1 A mT r < I . . -. .. . .. � . . , = ' � i`._... ✓" •.i. ` (1 �^ ' a ' ti .� �^ D =. _ I +.. ..'�~� '. �+.i-1-� � ,� r ?r ~� G) i- p v � r „ • ;. . �?: ; �� � . i x ; t' � o I -. ; . �.� � i� "I '�' � >) _ I .r`� „ v �lin � ' Gl " N ., . . � . j{'_ i�' ��'�;, i � i � '; C-�tl... 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