HomeMy WebLinkAbout0815A (4) 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
Signotu�e oF Permiuee Dme �
�
� p C
T � � � r =� �� 7
.C.� )+ C -Oa 4� 4� � n
:S ' r �� a { G ` � S
%�c � ." r, c �; m �c: t, c� .yc.
m'�i n =i �i m Z n � � �:
y� O .n � � � �
1� -. � m � �, � D
) O � �� p � �;
i
�• m �� x
r G,
. �"J
� � . �_ .
; � 11� �"�� �� a
z � ' � '1� =•- m
N �
'O • \,, ��
n - ,'� ('�. N
.-► ; .,
� � a
9 0
UN �%
N
z I L
O �
N ' I c
� �:
� m
T
N
'O
n
--1
O
�
N
Z
O
N
��~����� �
o.� cg�fo ^' g-���.�����mo�Q'�g
� � �j�0y� ���^�VI� CT'"�� � �C7m y i c
O � � , � � � �pl?r�V� _ O ON<5�� . +�� � G
9� g^ 3o ��a`°' inc:�� a �--ioocA�+ � r� 2
� @ '17 m a,�m ���.� -0.a �'i �ar��-' iy��n � n 3 m
w
� (� S Ca���o`�' mo�"`="coim�p�`°�ia��� �
. ,y, � �?ui��-�r y � m O��cD C. � O � Q1
' O � �� D������ ���Z�r��a�N � r
I+ C fJ-Q,' s y 4 mA m c� F�c"c� 3�Q O
� � mw Q..' :c�x.'C,aj��=� S �
�� ��� � � � � f
0 o c`� c �x 70
. � � �p�.�,�{?�O�O o�N ' ��Oc� � � �
N �tD O ���m W���"���' � n
� � C� "����m � m� nvl �'m �' r
� � ���moa,'�a-�i Q3=v�wm�$� c ��� 'D
$��mm�o �o� i� _.�c mt,�^ $ =,c 77
�+'�m' m��N `�$ 3c�?��c��o3$w ��� •�
pD0 5�o�,m` m om �m.i0...� K
yo �� �n �m � g'ia'^my$m =�^�' o� Z
m�o ��'�� -.1 � m� �4' �o�` y -.�
• S1 3 �.tQ N^ 7 � � ,,,,,�J �O] fn� n V .
�►��O� y�fb ���W�m c 4f��q w .
�co���z,� c/9 �'� a� Nwao� --5�
' �? om��� � o'���Q��v,�1O��` �w
a�3��K A i �,_�'^ -��-�--
, a
_ ��___-.—_—�_ -�-
_—_.