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HomeMy WebLinkAbout1810A (10) , � WORKERS'COMPENSATION DEGIARATION qpp��CATION FOR PLUMBING PERMIT � � 1 here6y,oftirm Ihal 1 hove a tertificate o4 mnsent to self � 7gA887A , _ , _ . . . � . insure,o�a certificole of Workeri Compensotion Insuroece, CE 817(REV.8/88) - . � - � � �� � U -� � or o ceriH�ed copy thereof�Set.3800,tob.C.) COUNTY OF LOS ANGELES� � DEPT. OF PUBLIC WORKS acyNo.73WC00504d�/jy Nationwide lified copy is hereby furnished. � ' � �- ��� �t 25 �`Plan`24� ' " . . � � FORAPPLICANTTOFILIIN(PRWTORTYPEI BUILDING r r �-. � Cer�ified copy is filed with the�o�nry building inspec- ADORE55 24382�'East Naa`Court . riondepnrtmenl. NUMBER FIMUREORITEM � �E LOCAIIri .. . . . . � . - Dole � 9-9—�7 AppliSanf Now Plnmhino �NATERCLOSET �� D�2IIIOIICI . PFAREST , . . CERTIFICATE Of E7tEMPTION fROM WORKERS' � enrH iue� CR055 Si. � � . � COMPENSATlON INSURANCE. S��R OwnIER � SLdID8Ie8 �CBI.�POII1j.8•IIIC.:� � . ..(Thi���etton nHd not b�eomplN�d if Ih�work Inrolv�d by - ��l, . ' . . .fh�p�rmM If}or vns 1lundr�d dollOn(5700)Or I�u.J . LAVATORY qDDRE55 3151�-Airwa ,`Ave':�' Ste N �� � .I cer�i{y.�hot in ihe performonce of the work for which this .- � . -- permi�is issued,I sholl no�employ any person in eny manner SWK �'TM Costa Mesa'�� TE��NO'8 0-10 � • so as�o become zubject to the Workeri Compensation Laws. DISHwASHER � - � , , CONTRACT �-•g Applicont QOTHESWASHER � � - qpp�u 'Ll(yl 5. _]�Il ont Drive � � pCE TO APPLIG4NT: II, aNer making�his Certifica�e of SWUMAiNGPOOIRECEaTOR p � � ..�mption, you should bacome su6jeU to �he.Workers' Anaheim �� Compensa�ion provisions oi the Labor Code,you must forth• ��rr- ��'�'937-39�2 . IAWN SPRINKLER SVSTEM � with comply with such'provisions or tbis permit shall be STATE LIC, -deemed rovoked. � - �-�� ' � . WATER NEATfR ��c�Ns�r+o.426109 CLASS �(�,, ' ' �. UCENSED CONTRACTORS DECLARATION . MSTRKT NO. PROCESSFD Bv � � I hereby affirm tFwl I am�icensed under provisions of Choprer V GA5 SYS7EM OUTtETS � �(mmmencing wi�h Se[tion 7000)of Division 3 of IF�e Business OUTLETS OVER . . � n ond Rofeuioni Code,ond my liceoae is in full fwce avd effecL � 5 PER Srs�at FINAL �/��/�o VALIDATION a � DATE Q ticenae Number 426109 tia Cla:s C36 � �tew Plumbin FiNA� /�o,�r-�—, Camrocto g Date 9—$—$� BY . � O ❑ I om ezempt vnder Sec. ^� ��,�(; U W 6 B.BP.C.for this reoson � � Plan check fee +_ • • • • •5 2 _ Date: PLUM6ING PERMIT ISSUING FEE_ . ► � � I • � Q B.O O � Signoture . . TOTAL FEE �+ � � C L O O c=i � . . � Pb�theck oPPltcont �. . O p.� 7�8 7 � . - SINGIE FAMILY . '� l FIOME OWNER-BUILDER DECLARATION � Name ,� � _ ,.breby oHirm�hat I om exempl from Ihe Conhator i license p�ress�� � �- � � � - - � - - �� Law fw�he followinq reoson(Sec�ion 7031,5,Business and � Profeaslons Code): � CifY _ � - ❑ . . .. . . . .. Tel.No. ..... .. . �-, . . , 1,as owner of the properly,will do ihe work und�he , , , - structme is not intended w oifered fp teb�Seclion .. . . .- . . . . . , . . . . . .- . . 7044,Business and Proieuiona Code). � CONSTRUCTI�N LENDING AGENCY --� �-���- � � ��- � �- � �� � � � � � � -�- � -�- � � I hereby affirm that there is a tonslroction lending agency for � � - - � the por{ormonce of ihe work for which ihis permit ic issved - - � � � - � � � - � � � � - � ' (Sea 3097.Civ.C.). _ Lender's Name � � lender's Address � . � I cenify�ho�1 have read ihis applimtion ond stote ihot the . _ . . . .. .... _ - _ . ._ ► . .. . . .. obove iniormo�ion is corrocL 1 ogree ro comply with oll Coonry ad�nancas and Stme laws�egulating Plombing,and heraby , . _ _ _ _ _ , .. authaize r preaentatives of�his Counly fo entx upon the - � � Cb tioned properfy for inspetti p o . �� 3EE REVERSE FOR EXPLANATORY tANGUAGE ignotwe of Permittee ote � � �Z C � n 2 G1 � A C � . _ , _ . , .� ._._.. . _,. 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