HomeMy WebLinkAbout0821A (4) WORKERS'CO.M.7ENSATION DECLARATIO�1 APPLICATION FOR PLUMBING PERMIT
I he�eby,off�lm Ihel I hnve a carlilice.le o(consen�lo se�f in- �'��5 D%w ai87 lI
su're,or o cer�ititote of Workers'Com ensoiion Insu�oncr.,or a ��p��A ' I I
P CE 9�7(REV.B�F6)
certifie.d copy rhereof(Set.3800,Lob.C.) � U
aoi�cy No.Z3I�CQOSD�xAQ�+rn�yNA1.IQlIL1IIIZE— COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Ceriified copy is hereby furn�sh=d. �� �
FC4 PFPIICANT TO fl��IN�:4I�'T C2 TYI'F.) °U'LD"�'(i
fZ Cer�ified copy is liled with�he ceunty building inspechan neee:ss /�203 EAST PEAK �QjJ
Ld de!pertmen�. NU.'9ER fiXTUREC4ITE�.t � F�E ��,�Lt1Y
�5'ATE4 CLOS'_i(iORET) D��
Dore 9-1—$$ App��contNEW PLUMBIAiG 3 6 18 r:faciST
CERTIFICATE CF EXE.MPTIO:V FROM VVORKERS' R.'�7H TU3 i Z Ce055 ST. :��T•
COMPENSATION�NSURANCE SNC'rVFR I O'•��`�R $$AMAT Fd ]��
(Thi�aection ne�d nof bs complafed i41ha work inralvad by _ ...,�,ii
1hv parmit it for on�h�ndred dollar�(SI00)or I�ss.) LAVATCRV I nD�'•F55 ur
I ce�tify thol in Ihe perfermoncr.of:hp work!or which Ih�s(�P�-
mit is issuod,I sl•nll no�employ ony person in�ny monner so 2 S��K 12� ��T� COSTA MESA TE���'��85�-1��1
os to becem=subject to ihe Workers'Compen�o��on Laws. D'SHVlaSHER
6 co^:r2perc
IDoie APP�iCnn� CLOTHES VJAS4Vrq I AC�PFS$ ��+
I NOTICE TO APPUCANT:If,ofier making thrs Ce�iiiicate.o(E�- �ll���uPQ�'.Zp�V
emp�icn,you should be.come s�bjeti�o the Wcrkers'Compen- 5:':'!f'r:1'G POCL�'CFPTO�
y ,. C�TY SEL.NO. _
Isa!ion prov�vons of ihe Labor Codr.,you musi forihwiih comp• �q�yN camn�r��o�yc.;;., T al�u
� ly wlll�such provisions o�rnis permi�shnll be dr.emed revnk- SiATE liC. _
rd. 1YAiER F'EATER II:ENSE NO. CL�55
� LICFNSED CONTRACTORS DECLARATION I C'ii4�.i KO F'�OCfS�CD 9Y
I h�reby ofi�rm thot I om I�censed�nder�rovisions of Chopter G.+.S SYSTE!.1 � Cui�[i5 J�
9(commenc�nc�w�ih Sec��on;000)of Division 3 0(the Business UU?iCTS OVE4 �
and Pro'ess�ons Code,and my license is in full force and ef- 1 5 P[�SvSf[t+ 1 I 5� FIIJAI�L/ vG� V IDATION O
fec�. DATE ( Q a
License Number la�F+10Q Lic.Clasz �-3F U
I FINAL �
Co�rracio� NEkT PLUMBING Dalr._8�1�8 I 6Y � p
� I nm exempt under Sec. � W
a
8.8P.C.(or th�s reoson Plon check fee ► Z
� �'O�P� �'LUN.3iNG PcR.v:iT i55UiNG FEE S 1 �
� $ig�a�ure L ::Q E�l. I ri
TOTAL FFE
SINGIE FA1,11LY Plon chr,ck opplicont �!• • • e u j
HO.ME OV/�vER-BUILCER GECIARATICN
I hereby alfirm tnat I om e*empt Irom ih=Co�!roctcr's L�cense Name � ° i � (;,(}J
Law io�fhr, following IP�50�(S�c•�cn 7031.5, Business cnd
Pre�essiors CodP): Address � �� �� , —
� • 11 �.... J_
V � 1,os owner o(Ihr,property,will do the w•ork and�he City ici.No.
I structure is not�n�ended r.r oifere.d for sal=(5�[IiO�70<d, O C� I � —�C
Business and Pro'ess�ons Code). .
� CCNSTRUCTION LENDING AGENCY •
1 hereby aflirm Ihai�here is o conslruclion lending agency fer
the pe�formance of ihr.wo�k icr which this pr,rmit is issued
�Sec.3097,Civ.C.).
lender's Name
Lender's Address
I cerrify tha�I have read�h1s applica!ion ond s!ole Ihn�Ihe ►
above informa�ion is correc�.I o9ree�o comply wi�h all County �
ordinonces and S�are Inws regulo�inq Flumying,ond here6y
ouihorize represeMalivr.s ol ihis Counfy lo enler upon the
ob ve-mention?d properry for inspeclion pu�poses. ' -
��/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signo�r ef Perm�t� Dofe
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