HomeMy WebLinkAbout0817A (4) u-ORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT {�
I hereby,ofiilm Ihal I have a cerii(ica�e of cons=nt to self in- jh�>;�4�g�
� suie,or o cei��fica!e of N�orkers'Compensetion Insurance,c�a �E s,,,�E�.A,A,,, . . ��
tertiliad capy thereol(Sr.c.3A00,Lob.C.)
vol+cy No.Z�WC005047�Q(�nyNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIG WORKS
� Ceriified cooy is he.rr.hy furnishr.d. '66 LA ' � '
FCR A�P�IUNT TO FILL IV(FR'VT CR TYPE� r��������
� Ceriifiedcnpyisf�l�dwi�hihecoun�ybuildinginspection nCC:es44210 EAST PEAK COURT
departmenl. NU'•"GER FIxTU9E CR iTE'A (d F[E �pCAIIiY .
Dnie9-1-88 aPPuca�d�EW PLUMBING ��'ATE".CLCSE7(TO�ier� 6 18 n_no�st
CERTIFICATE OF E%EMPTION F40M VYORKERS' Z B�TF�T�3 12 CRC55 5T. �
COMPENSATION INSURANCE SI+OwfR ��•�1�R LEA T.TMTTg
(Thit socllon nwd nof be complafrd if the work Involv�d hy �.p�i '
th�permit is for ono hundrad dollars(SI00)or Ivaa.) lnvnTC4v ,;D�rtESS 1 1 AIRWAY AVE. UITE N
I ce�rlfy�hot�n ihe perfermance oI!hr.work for wh�ch fhls per- SiNK � �
m�l is issued,I shnll not em lo an erson in on monner so 12 ���Y T��.�O
P Y YP Y C.OSTA MESA 850—
os to hecomr.su6ject to�he Wo�keri Corhpenzet�on Laws. D'SFi:•/AS���R
Cor+renC�C� DTITMRTU� �T
IDotE Ap�li[onl CLOTH:S WAS�+CR I AC�kE55 '
( NOTICE TO APPLICANT:If,af�er mok�ng�h�s Certi(icote of E.- .u�11i —
em ifon, cu should 6ecome sub'eU lo rhe VJmkeri Ccm en- SW:�vY:\G FC�L FELE�T07
P Y I P C11Y TEL.t.�.
soi�on prov�s�ons ol ihc la6or Codr.,you musi torthwith comn- ;��.�.;�pp�.;�;�o;y�,,.., I A;�[� TM �
ty with sach provisicns or ihis permil shnll be deemed re�ok- � Si�.it uC.
ed. ' Yl,1TER HEATfR IIC�NSF f�'O CLP.55 _
LICENSED CONT4ACTORS DECLARATICN 6 I C:S�c'C'r:0. r,'OCESS[o�r
I hereby aflirm thnl I am licensed under pro�isio�s c(Chap�er GAS SYSTFh1 6 OUTLETS /�
9(cammencing wi!h Section 7000)of Drvision 3 of lhe Businnss CUIIE:S Ov[R �
{c d Profess�ons Code,and my licensn is in full force and Cf- 5 PFR SYSIE!.1 I FINAL ^/� C/� VALIDATION O
DATE �Q/
l+censr.Num�er 426109 L�c.Class �'-3F
U
FINAL ¢
Conirocio� NEW PLL1:�IBING Daie 8_31=$$ I BY 0
�
� I am exe.mpt under Snc. I � w
a
B.&a.C.fo�ih�s.eason Plan check fee I ► `�
z
Dnrr.: PLL1MBIhG PERf.�.IT ISSUING fEE 5
Signa�urr.
TOTAL FfE
' SINGLE FA.'.ILY —��
H01dE OWNER-CUIlOER CECLARA110�1 Plan chrtck npplican� .
����.%�
I hereby affirm ihni I nm exempt from thc Conhacror's Litensr. Nome
Law for�hc following reason(Section 7031-5, Business or.d ;i e • . . ,.
Prafessions Code): Ad�lrrtss
� I,as owner of�he proprrty,will de thr wor4 ond�he �'�Y Te.l.No. I • , ����
shuc�urcisnotint^ndedoroffercdfcrsole(Sec�ion70C4, • � I l�,f�.�lii�:
Buvness ond Profesvons Code.).
' CCNSTRUCTION LENDING AGENCY ► G S � � -(5 L>
I hereby o!(irm that ihe�e is a construcrion Iending agency for �
the performnnce of the wo�k for wf�icfi this permil is issucd
(Sec.3097,C�v,C.). . '
Lrnder i Nome �
Lender's lrldrrss ,
I cer�ify that I hove read this opplrcotion and srote�hoi ihe ► "
abnve infermation is correct.I og�ee io comply with oll Counly
ordinonces and 5!olr.I�ws req�lnting Plumhing,nnd herr.by .
authorize repre5enrative5 0��hi5 Cou��y�o enter upon fh�
o ve-m�i�oned p�ope�fy(or�nspec��o purposes. �
�• ,� SEE REVERSE FOR EXPLANATORY LANGUAGE
S�gno�ure of Permitten. Dole
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