HomeMy WebLinkAbout0815A WORKERS'COM7Et�SATIONDECLARATlO,I APPLICATION FOR PLUMBING PERMIT
I heleby,affirm Ihnt I hove a terlificoie o(consent to self in- ���ACow eia� n
Sv�e,or o ceiti(ico!e ef Wnrkers'Compensaiion Insuronce,or o CE ei7(BEV.Bifi6� I 1
certified copy ihereof(Sec.3800,La6.C.) U
Pol+cy No.73WC00504�QJ��yNATIONWIDE COUNTY OF LOS ANGELES EPT.OF PUBLIC WORKS
� Cerhiied copy is hern6y furn�shed. �
� FCR APPIICANT�O F!LL IN��4:\'T OR TVFE) L'JIIC'NG �w��. � �
Cnrnl�ed copy is f�led wiih ihe couniy building inspecfion aDC�FSS G �.
deoorlr�ent. h'll:•3FR FIXTURE CR�i`.'A (e' fFE
pa�e 9-1-88 ,npvu�o„ihEW PI,IiMSING 3 WATCR CLOSET(TOiIET) 6 18
1OC°"iy DIAMOND BAR
M1'[PRFST
RATH TUB cacss sr. GRAND AVE. � •
CERTIFICATE OF EXEMPTION FROM WORKER$' Z 12
� �OMPENSATIONINSURANLE ' 2 SHOVJ£R ' 1,2 O�:�r:=a B�,LEA�LIMITED
(ThI��acNon n��d not bv complvfod if fh�work involvad by r,+qi�
IM p�rmit i�For one hundred dollan(SI00)or les�.) 5 LAVATC3V 30 apc;ESS 3151 AIRWAY AVE. SUITE N
I tertify�hol in ttir,perfermonce af the work(or which this per- S�NK
r.i�i�s issued.I sholl noi employ ony person�n any rr+o�ner so �'T`'COSTA MESA T`•� ^O 850-1001
os to becomr.subjen�o Ihe Workeri Compe�s�iion Laws. . 1 . ��,�q,•�pcH�� b ce�rancre ,
Dale Applico�� 1 CIOTPFS Y/AS�'ER 6 �v_EW PLUMBING CONTRA�TORS INC ,
NOTICE TO APPLICANT:Ii,oiter making�his Cr.rilCm�e of Ex- ����SS 2L4��DUP N �
em iion, o�should become s�b'ecf lo thr.Wer4er5'Com en- 5'Ni.V�.V�iNG I'OOL RFCFP:C�
P Y I P UiV TbuF 'Fl.�'O.
so�ion provisions of the labnr Code,you mus�(cr!hwith cemn- ;�����;��p;•;�;{�,�,y5�;�,; � p?�...,::I'1a �— �2
iy w�m such prov+s�ons cr ihis F�rm�i sheli be deemed revok- � � S�nrE i�C.
ed. � 1 WAT[R HFA7FR 6I l'CFNS�ND CI�55 —
LICFNSED CONTRAC70R5 DECLARATION C�S:�ii,i n0 P4C['$!:E7 BY
i hereby off�rm that I nm licensed unde.�p�ovision5 of Choprer 1 GAS SVSfE'A � OUiLE15 (I �v
9(mmmencing wi�h Seclion 7000)ef Div�sinn 3 ef ihe 8uxiness 1 L`U.fETS CVER 1 )ro
and Pro(r.ssions Code,and m lice.^.se is in lu�l lOr�@ a�d e�- 5 PE2$YSi;.lt I c 1/� /� �//� ATION �
ieci. Y I DAT ��f � a
l�cense N�mbor 4261a9 tic,Closs �-36 v
FINAL
Co���acio� NEW PLUMBING ooie 8'31-88 I ov ;/ O
� I om e.empt under Sec. � �
B.BP.C.(or ifds rr.ason plan check fee I , _
Da�e: PLUM9ING PEFMIT ISSUI:�G FEE S lO O
Sfgnature TOTAL FEE 11(+ �� �Q F 1,�j 1';
S�NGLE FAI.'.ILY� Flon check a liconi i� •
HO.'.1E OV:t�ER-BUItD�R CECIARATION Pa . • ° " "
I hereby afium ihoi I om e�emp�from�he Corlrauor's License Nomr. � ° 1 � [i.V V
L�w for!F>(ollowing rr�son(5=clicn 7031.5, Business and
Arefessior+s Cod�): Address , � � 1 / ,��.,_
� 1,es ownrr ef ihe p�cpe�iy,will do ihe wo�k and ttie �'�Y Tcl.No. i
s�ruclurr is nal in�endcd or of(ered(or sal�(Srclion 70d4, ��'j � —�'C,
Business and Prolessions Code). . ,
CONSTRUCTION LENCING AGEA'CV � ' �
I here6y affirm tha��here�s n constroct�on lendirg a�ency far �
1he perlermance of�he work ior wh�ch�hrs permi�is�ssund
(Sec.�097,Civ.C.�.
Lr.nder's Nomc
ILender's Add.ess
I certify thol I hove rend Ihis oppl�tolion and slole Ihot thr. ►
o6ove informa��on�s cerrect.I a�rer.ro comply wiih oll County
ardinances and Siate lows regulai�ng Plum6ing,and hereby �
aunc�ri:e representa�i�es of this Ceuniy to enter upan �h�
�ob ye-me onad property for inspection purpases.
/, ���r � SEE REVERSE FOR EXPLANATORY LANGUAGE
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