HomeMy WebLinkAbout0816A (4) WORKERS'COR1PiNSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I he?eby,affHm thot I ha�e o cerid�cate af consent�n self in• �'�26 Dvtv ar5� /�
suie,or o ceilifica�e of VJorkers'Compen�alion Insurance,cr� CE flll�l EV.BiP6) � I I
certl(fed copy iharnof(Sac.3800,Lnh.C.) COUNTY OF LOS ANGELES DEPT.OF PUBIIC WORKS L�
I �oi�cYNo.73WC00504tA�p�,y$�p��E_ � LO PLAN•25 TRACT•
I � Cerli(ind co�y is hereby furnishr.d. '
� F07 n�PLIClNT TO FILL 1Y(�d'N?CR TYf'E) 9UiLbiNG
Cer��fed mpy�s f�lad w�i6 iha couniy bWld�ng�nspeciion aee.�ss 24218 EAST PEAK COURT
depar�menl. NU".•!SF4 fl%TU4E CR ITE!A (c` FE'_
LCC�LIiY
oaie9-1—RR Applican�N .WP � TN• �'/nTE4CLO5ETITOI!ETI 6 18 �'��4�VL�1L
n�rr,:esr
� CERTIFICATE OF EXEMPTION FROM WORKERS' 9nTF�T�3 1 CRC55 ST. AVE�
COM.PENSA710N INSURANCE 1 �110Y1E4 6 i 0"h�R BRAMALEA LIMITED
(Thls��clien n��d nef ba tomplafad ii Iha work Involv�d by �,��i
tha pormiT li for ono hund�ed dellurs(Sloo�or las+.) �nvnrcev Zq nDDRE55 3151 AIRWAY AVE. SUITE N �
I ce�i�(y iho�in ihe performance o(fhr.werk(or wh�ch ihis prr- SiNK
mil is is5ued,I sh011 no�employ any p=rson in r.ny mnnner so ��TY COSTA MESA Tf� �'� 85�-1��1
as to beceme subjed�o ihe Worke�s'Compensation lows.
DKyWASF+iR cetirzncrc�EW PLUMBI1vG CONTRACTORS, INC
Da!e � Ap�licnnf 1 CtOiHES\YASNF'� I 6 q��S,SS
NOTICE TO APPLICANT:If,af�er mok�ng ihis Ceri�6mlp of Ea- SWI"1.S"NG F'C,Y.;RfCCPT04 �1_ R V'
I empiion,yau should 6P[ome 5ubject to the Workers'Compen_
salion provisions nf Ihe Lo6or Code,yc�musl forlhwith comp- I ��TY ANAHEIM �E��N� 937-3972
I ,n�,yy ccqiyr,ro cvcr�u,
ly with such provisions or th�s pr.rm�t shall be deemed revek- � � 5�:.�E i�C.
ed. WATFR HEATER I LiCENSE ti'O CLA55 —
I LICENSED CONTRACTORS DECIARATIC�I I D�Sia'CT NO FP^�FSSFD 9Y
I Fereby affirm ihol I cm licens?d iinder provis�ons cl CF.apler GAS SYSTE`h OUTlE75 /J
9(commencing wiih Section 7000)of Drv�s�on 3 of ihr.Businr.ss CU7tF15 CVE4
and Professlons Cede,ar.d rny licr.nsr.is in(ul�}orcr,and e(- 1 5 PE4 SYSfEr.1 1 I 5� FINAL ` VALI ATION r
fect. I DATE —�y`� a
License Number 47(109 Lic.Closs C—�36 O
I FIN�L V
Co�o-acro� NFW PLUM.BINf�_Dare 8�1=88_ I RY C� °C
O
r
� I U
I am exemp�under Sec. W
B.BP.C.for this renson a
Plan check fee � ► Z
� Dntr: FLUMBING FiRM1T ISSUING�FE S
Signoture Q I
TOTAL FEE I 14 OO �C��.C)F'.
SINGLE FA.+.ILY
HO!AE OWNER-EUILDER QECLARATIQN P'an check opplicant ��� � � � �j
I hereby offirm iho�I om c*emp�irom thc Con:ra:�or's License Namr.
Law for�he follow�ng rensnn�Section 7031.5,Bvsiness cnd � �'i f ��li J
Professions Code): Address
. • " � I i. i�n�
� 1,ns owner of�he property, wlll do the wo�k ond ihe �'�Y Tel.No.
structurn is not in!ended c�o{{ered icr sale(Sec�ion 7044, � O r�.� I —L�
Business and Professions Codr). ' , ,
i CONSTRUCTION LENDING AGENCY
_ I here6y nffirm that there is n construction lendin9 agency for � __
thn pe.r(ormance of ihe work for which ihis permit is issued
(Sec.9097,Civ.C.).
lendPi s Nome
lender's Address
I certiFy�hnt I hova raod this opplication and sla`e ihat Ihe
above iniormotion is correct.I agree�o comply with all Co�nly ,
ordinoncrs and S�a!e lows regula�inq Plurnbing,and herehy �
aulhcrire represe.ntolive.s of Ihis Counly lo entr.r upon thc
�obj�ve•maJ�+ioned preperty for inspec��on p�rposrs. .
�� �.3,�7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si9�O1��P.Of PP�rt1i11PP Do'e "
'
;
G� '� ' n n V
�- T° � 3, C O m t� C O
`v c`� _ � `" � � c v G' �
_� .-� -", m s; m v ,� c� s
rt-Ni r [� -�'i � r� 'a � c � 1
➢T U � � � � O
vr ^ � = Z V y
� p � � '� 4l � �A
i� n� �
. r p N
` ,
'
ti ❑
! � �. �
Z �� � T.
� • 2
'b •
o � ;� ``�:
�.► . - �
� � �' + ~ m
�
� o
z � �'
O N
m � �
cn . . �;
�
T
�
. 2
N
�D
n
�
O
. y
N
Z
O
N
$ mG"
�a � °.��-' � i���� �
a,
� $womu�, o3ci" �
� 5����'��y�G ��y'rn� c�aDm U �Q m �
� � � G° �. � � rom�S�vC��DyO �ON���c ?$`" �-, °� �
� m � m � v��anmA�� �C:K1 � �~��C•�'� z
� m � x �Q^m �m > >o$c��m���ti� N4�� f�'1
" m Q oYo' �Q� : _•" °' oam�, '° 3 70
' ' .« 3 �v,�iS� r-c�._, w o�� �om .°' oso W
. a � o� go�r� ��$ g$'�_oC��$ �� �
� ...-, mo _ �
= c o=(y"' 3o y�g mn m ."�=ci�-, e� Qa t^
� �m wma�u' q �wx -pa'��' 3-�-3 �
� . iY1 a < x�'..�fA N N� 6� � .7�.m J�.y 7�t�"'y� QI m
� m o`°�'_cci? �Q o03 � �^ � �^ o�o �x �
� g5�.?a��oo� =' Haa�'i-• �' �Qc � O
m� o =-. do � ���pn � W���� o7��v R1
' ��j$,�CSD O���'�g p'"' =�o?CDb y� � C7
O�nm�iOQO� o- m��cbR�2»tQ ���� �
a: y � q
`'no' m �,� A m$ �com�c"r° o�go�c�m3 •�
O �'a Q O O n�Cr^ `n tD,,. �
. �m tn p��q' -' tDO�:i�S� '-�c�"� pn �
O�<.OQR:[)�m � _�7ONO� _� ' O7� Z
. m� ��.m i�°„ _ � �u' o3m��� �+a �
" y W^.��nb� pp C� � ��.��n�4']-jpcWQt
. O ��OJ p, [yw �a�n � �n 'r V;p
��O ';ia 6 (%�c, -
. m =o�Q, 7 i�;=��?�ov� n-
�¢� ¢i<<c' �e
'_�_��_���•.r-