HomeMy WebLinkAboutNo Permit Number (126) � WORKERS'COMPFNSATIONDECLARATION AQD' �"ATI/1w CAD �� 1 Aa■ I��P rfP �p�
j I he�eby,affirm ihai I have a certrticote ot consent to selt in- 76N667A✓'�YV 4���/ �� � ��y^���1� !V 1\ A L�VN�\�ttr`J r ��,YI1� i I!
Y sure,ar o rertifi;n�e o't Wcr4ers'Campr.n}ntinn Insurance,���n C[i317;kEV,S;fi6) I
i r.r.rfified wPY inerenf(Sec 3800.Lab.C.) �
g 73TJC0050�ia�n�[� Nationwide COUNTY OF LOS ANGELES DEPT.OF PUBIIC WORKS
Policy No.__..._._.—_. �76 y__---_ LOt 28 Plan 24 Tract 42578-8
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� � Cerlified copy is hr,reby furnished. . _
FOR.4F�L!CAM 10 hfLL�N(PRINiOR NPF.�. Hll'�.,>iNC;
� � 9—�ied89 sf�ledwilhthemun�ybuildinginspection -- r -- --- - --��DD�i5,896 S'. L2ylHrid DY1Ve
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department. NUMBER� F=x1i1RE OR 17[M �FFF. �
_ _ .. ._._.. _ T—�LO����IiY
� Dale`_ Aoohcant Neca�Plumbing .'"� �va�rh uoser,roue�;--...--,-- i � --��F,fST D -----
iamon Bar
"� , � �N;s;;, Grand Avenue
' CERTIPICATE OF EXEMPTION FROM WORKERS' {�G eA!H iUs J ___ ___ .._-__-___
! COMPFNSATION INSURANCE � �� � -� ---� �� �'.v'�FK '
, s�oweF i ��' � Bramalea Limited
�� nhisssesued I shall ot�6e�om leted if the work involved b � SiNK �� � i�'7 � ! �
I P Y �7 U.nu �
� The parmit iz for one hundred dollars(5700)or less.) t�VATC�RY '�. �aL`L'NESS 3]_51 [ilYNi3Y �_1VeI_1ll8, 5ll1tC- N -
g� _ . ' '_.—..._
I certify thal in ihe per�ormance of ihe work for which ihis p..r� �� � I y t`.,�`
� �' y<,�y pe�so���a�,y���„„P�,� __._ _. ._i Costa Mesa � 850-1001
j oisHwnsHER � j�
� oore I_ a�pl�canf_�.p � c_o�nes was�re ` _ � i T *�- ^�'RP�T�� �;ew Plumbing Contractors,Inc
T as to�become su6�ect to tne Workers'Com ensahon Laws. �
-- _ __ _ __ _____ ' �co
t--} }d �'ss -.._._.. . . ._.
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NO?ICE 7C APP!ICANT�tf,ofrer mok,n his Certi`,icaie ul Ex- y � „S�DuPUI1L DY1V�
" n t on, ou should becurrie,sub ect to the Workers'Com en- 1 I SWIMMIN.,POO_'�-CFPTOR I -
'P� Y I P �_ .___.__ _�---_---�'i�Y !hL.NU. �
�.: P .... .. ._��lJA-EN HtAiFR _-��
� satior�Frov3ions of the Lo6or Codo,you must forihwith mmp- ��WN SaRiNK�ER SVSTFnn� � -
ly with such provlsions o:rhis pennil shall be deemed rPvok � r"nTE
+ ed in F,us tio. 426109 ',iHss C-36
� UCENSED�GNiR,�CTOKSpECLARAIION -- �-- � � UiSrkIC1NU PR0�f55iunv .
GAS SYSTE/A (,:UriEi i � �� `����y,��,,_��
i hereby nf*inn!hot I om!�[e��.sed;,nder provisions of Chcapter t
� 9(c mrnmcing w;?h Sr.chon?WO'�.of D:ei;ion 3 nf ine 8usiness �OIiT�,FiS UVhR �"A�•5'`�
and�Professions Cade,aod license�s in f�l! orc�a:'nd ef 5 NEk SYS7EM � � /
my - �--- FlNAL �-
a - - � YALIDATION e
k ,�:i. i ; oarr ��3-4 t'� � �"
� License Number 426109 Lic Class C-36 - -- —�— �-- � 'a
5-31-89 �-- — ------ -- ---
rwn� , er
i -T�— BV �j..- .. �
; co�r���fo� New Plumbins�_o�rP � �c.-
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� � I am exempl under Ser _, - -.� . . .t._ �= � �'' !.... .. G7
J __...._—_- .- �. '� 'r.
fA.
B.&P.C.for this reason c � ;; e ,: „ �
� -- Plan check ee I ' ` `n - " .'
-- — -- ---- n
�� —�--- --� ---- �a}�� PLUMBING Pt12MIT ISSUING FEE S : j a `j ,
� Slgnature /�y ��
_ —___._
5 SWGLe FAMItY _._-__ _.. OTAL.`C—_ �_�/, ��' .a ..� i !�.,>';�� "?-
0 � _ 1/ � . .. . s -
F HpMF OWNER-9UILDER DECLARATION Plon chr.ck npplican! �,}',C' __' _z
....._-.. ___ : .
� I hereby affum�hat I om nxnmpt from+hc ContraUor's Li<ense Name
Law for!he followmg reoson !Section 7U31.5, I3usiness und - -�--- ---� ----
' Professions Code): Address
� _ - . - _ .___ _... _.
� � I,os ownr.r of tne prnperty, will do !hr.work and!!ie �iry Tel.No
; structure is not inicnded or offered ror salr,�Ser.hon 7044, - �--�--����-���- ----- ---
: Business nnd Frofessions Code.)
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CONSTRUCTION LENDING AGENCY �
I hereby affirm ihat ihere is a ccnsiruction lending agency for
: the performance of ihe work for whicn ihis pe.rrnir is issued
(Sec.3097,Uv.C.).
lender's Name
Lender's Address
I ceriify that I hpve reod this appliw�ion and stote ihat the
obove infr rmotion is correcf.I agree b mmply wrth all County � ,
ordinances and$lote laws ret�uloting Plumbing, and hereby
� author e representahves o! this Counfy to enter upon ihc
abo� �bned property for inspeciion p�rposes. .
�� � ��;'ry9W�.y'',7 SEE REVERSE POR EXPLANATORY LANGUAGE
�---
� S rin ur�of Perm�..�e � Date .
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