HomeMy WebLinkAbout0822A (4) `"'°RKERS�`°"".`E"SAT'°"°F"AR"T'°" APPLICATION FOR PLUMBING PERMIT
I he}eby,n(fitm�hol I have a ceriificn!r af consent fo self in- ��7���''�4�07 �
sure,ar a ccrtificn�e ol YJorkers'Cor�p�ns�lion Insurance,or a CE BI7(REV.AiA6�
cerii(ied copy the�eof(5ec.3800,Lab.C.)
Po�icy No.73WC005047�QQ��yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certifixd tepy�s hereby furn�shod. LOT: PLAN:24 TRACT:
�J Ceftified co s flled wHh�he co�m fC4 A�PLICA"JT TO�IIL�N IPR'NT CR TYP,) RUI�C'.'�'G
ny� y building inspr.c�ion :�r.r.:ess 24209 EAST PEAK COURT
� dOp���ment. �U.'.'9iR FI%TURE Ci IiE'.1 � F�� �pCaIITY
w,:,rea aoser�Te,ier� DIAMOND BAR
oore9-1-88 AppliconNEW PLUAIBING 3 6 18 ��[.RESi
CERTIFICATE OF EXEMPTION FRO,M WORKERS' 2 BniN iU6 1 Z cvess sr. GRr1ND AVE.
COMPEhSATION I�SURANCE O'+:��R
��0��.�4 a t e
(This svclion naed not bs compl�t�d I!fha work involved 6y 1 6 ,r` ��_ LI�t T
Ih�parmlt Is for on�hundred dollen(S100)or losa.) �AVATCPV 2[� qeC;F55 3151 AIRWAY AVE. SUITE N
I certify Ihat in!he pnriormance o(ihe work 1or wh�ch ih�s per- ci�;K
mii is issued,I sholl no�rm lo on � y ` ��TY COSTA �1ESA TE����850-1��1
P Y Y Person�n an mo�nPr eo 2
os 10 become subject lo the Workers'C�mpenso�ion Lows. D:SM'r'JASfie4
� 1 6 ceN:ancrc�EW PLUMBING CONTRACTORS IhC .
Do�e Applicant 1 CIOiF+ES V.�nSH'R 6 I -- --
A�CP:55
hOiICE 70 APPUCANT:If,nftei moking this Crrfificote o1 E.- SWI:":'iNG�:�FC[��C4 2141 $. DUPONT DRIVE
empGan,you should become subjeci to ihe Workers'CCT�P!1• [�TY TEi.!.O
sa�ion provis�arts oI Ihe Lobor Code,you mus�icrthwith comp- i qp�y ccq���viro cyc.�.., � ANANET_M 937-3972
ly wiin sucn p.ovisions or!hls permit shall 6e deemed revok- � � Si�iE UC.
ed� 1 WATFR HEATFR b l I�CEN$E M1O. 2 lO C1P55 C�
IICENSED CQNTRACTORS DECLARATION �•Si2•Ci�:0. ::OCESSED Bv
I heroby oif�rm ihot�om I�tensed under provis�ons cf Chnp�er 1 GAS SYS?F!.1 6 Cui�ETS ( /O
9(cemmencing with Se:��on 7000)of Division 3 ef the 8u<.�ness euri!�5 Cv:? �
ond Profess�ens Code,and my license is in full iorce nnd rtf- 5 P;4 SYSiE:r.� 1� 50 FIVAL �//�� ATION }
I �P�� 426109 �ic.���ss C-36 I DATE��� /�� �
License Number I V
FINAL �
Controc�o� NEW PLUMBING_Dnie 8-31=88 I 6v ,., '— O
❑ ' F-
I am ezempt vnder Sec. W
I o,
e.Br.C.(o��h�5 rec5on Plan check fee ► Z
Da�r.� FLUfJBING RRMIT ISSU�NG FEE S I
Slgno��re TOTAL FEE 108 �� '-G�C•�''''
SINGIE FA�+.ILY
HOME O`NNiR-BUILDER 6ECLARATION P!on check applicant „. e . o ��
I hrre6y nifirm that I om e.empr from�he Conrroc�er's Licr.ns= Name
Low fo�tha follow�ng rr.ason(Section 7031.5, 9us�ness and � • � l.��`•V O
Pro�es<�ens Cod^�: , Address
• e � �� ., _�
�.'
� I,os owncr of fhe propr.r�y,will do rh=work ord fh� Ci�y Tcl.No. I
structure is no��n�ended o�offered 1or sole(Secfion 7044, G�� � —'v C:
Bus�ness ord P�ofess�ons Code). '
CONSTRUCTION LENDInG AGENC�
I here6y n(firm ihal therr.is n cons'ruction lendinq agenty for ' �
ihn per(ormance of ihr.work for which rhis perm�i is�ssocd �
�Sec.3097.Civ.C.). '
lender's Nome
Lender's Address
I cer�i(y ihat I hove read this appl�cnr�on and siate ihai the ►
obove information is corract.I agree ro comply wi!h oll Coun�y
ordinance.s and S+nie laws reguloting Plumbinq,ond hareby ,
authorize represenia�ives oF+his Co�nty io enter upen Ihe �
obR e-men' ned property 1c�inspeci�on urposes.
/ �'�'�� SEE REVERSE FOR EXPLANATORY LANGUAGE
L�— s�
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