HomeMy WebLinkAbout0820A I WORKERS'CO!rFENSATIONCECLARATION ,��,,,po�,,,,97 . qpp��CATION FOR PLUMBING PERMIT �7
� 1 hereby,afi�7m that I have a cen�(�cote of mnsr.ni io self'in- �F�,��� � [, �
sure,oro cerfiiim�e ol Wo�kers'Compensa��an Ir.surnnce,or a ���p(qEV.Bi86) I I
cer�ified copy thereof(Sec.3800,Lab.C.) L�
I Pol�cy No.Z 3 F 1 C00504iffl 9,�6 hy�T j Q C 1 6[I D E COUNTY OF LpS ANGELES DEPT.OF PUBIIC WORKS
� � Cert�(ind copy is hereby f�rn�shed. LOT6 PLAN:25 TRACT:42 78
f=7 Cerf�f�ed co Y 9� FCR APhICAN�TO FILL!N(fRINT O�Z iYrc� eu:!r.:vr,
� U Q depor�menj�y�sfiledwithihe<ouni 6uil;lin nspe[lion NU V.B F R FIX1U^,EC41iE!d �a` F[E a"Cc'S5 24201 EAST PEAK COURT
iec�uiv DIAMOND BAR
I \YATER CLOSCT�TO'IET�
oe�P4-1—R8 ApplicaNA]�W PLIIMBING 6 18 kEAUFSi
ICERTIFICATE OF E%EMPTION FROM VdCRKfR$' , 3 BniH TU7 18 CRO55 ST. GRAIVD AVE.
COMPf1�5ATION 1I�SURANCE L �„o,,��� 6� c•:m:a g�,EA LIMITED
I (Thii�etflon naed nof bs cemplsled i!fhe work inrolrad 6y ,�pii
I thv pormit is For ono hundrad dollora(SI00)or I�s�.) fAVATCPY 2[y .�cc:ess 3151 AIRWAY AVE. SUITE N
1 cerufy rhoi in the performmce o(the werk io�which Ihrs per• 5'NK
I mii is issued.I shall nof employ any perscn in any monner so � �'TY COSTA MESA TE����85�-1�01
as lo br.rame su6;ed io the Wcrkeri Cempe�sa��on LOwS. CIS`�WAS�'.`4 ceti^ar.acq�EW PLUMBING CONTRACTORS, INC
� Dole. ' Applim�� 1 CIOTH[5 WASHER 6
� A�D-E55
NOTICE TO APPIICANT:II,a1�r.r moking this Cenifica�e,r,f Ex- Z141 S. DUPONT DRIVE
empron,yoo should becoroe subjen to ihe Workers'Com;en- S��i'r-'+'.i�G F'COl RFCFPiCR
CITY 1£L.NO.
w�ien provisions of rhe Lnbor Code,you most iorthwinc�omp- �nN,u co��• � A,�'AHEIM 937-3972
� ly w�lh sucli�irovisic�s or mis�e�mii sholl be deemed revok- � �Y`� �Vy� S7A1E tiC. _
ed. W/1TER F+E.4TER L'CE!.'SE NO CLn55
UCENSED CONiRACTORS�ECLARATiON 0.5TF�i NO. FROCFSSfD 9Y
I hereby affirm thot I am licer.sed�ndar pro��sions of CF.co�er GAS SYSTFM � OUTtETS )�
1 9(commencinp wiih 5=ction 7000)ef Division 3 of ihe Business CUi�EiS�vEv �
I ond Professiens Cede.nnd my licens�is in full force ond ef- 1 5 Pf'+SYSiC.Y: 1 I 50 FINAL �/{�� ATION >
i fact.
Lic=nseNumber 49Fi10 I DATE o-
9_Lic Class_��L_ �
I I FINl�L V
� C8}Gk�c�BLU:fBING Do�r._H�.1_$$ I 3Y °C
O
r
� I am ezempt under Sec. I . U
W
Q.
B.BP.C.for I!��s reason Plan check fee � ► z
Dn�r.: FLU-MeING PiRMIT ISSU:NG FEE 5 I �
I Signoiure TOTAL FEE *=n�;e,li i',
SINGLE FAMILY 11�F OO
NQME C'NNER�CUILCCR DECLARATION Plnn check opplimm e�j
I I here6y oll�rm�hol I am exemp�irom�h�Conrroc�o�s License Nome � � � � ���,`�
Low ior�hr.following recson(Secticn 7031.5, 6usiness n�d
Prcfessions Codr.): i.ddress
• � I •, n�
I � I,as ownr.�o(rhe preperty, w�ll do�he work ond ihe City icl.No.
i structure is nol inlendod or ollered ior sole(Section 70dA, ��:. I � —:t C
IBus�ness and Profess�ons Code). ►
� CONSTRUCTION LENDING AGEIvCY
I I he.eby o�(irm ihnt�here is a construci�on lend�ng agency lor ' '
�he perFermnnce oi!hr,wnrk for which this p�rmit is issuad
(Sec.3097.C�v.C.).
' lender's Name
lender's Address
I cr.riify thal I have read�his appiimiion and s:ate Ihal thr. _
above,informotion is mrrect.1 acree to comply with all Couniy . ,
ord�nnnces and$:ate lows rr,gula'inq Plum6ing,nnd here6y
o�thorire represen�olives of ihis Cou��y�o rn�Pr vnon rhe
a ve-m p�ioned p�operty for inSpeUion pu�pos^s.
� L�, !3.�� SEE REVERSE FOR EXPLANA70RY LANGUAGE
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