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 � �
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