HomeMy WebLinkAbout0824A (4) WORKER$•�oMPE�SAT�oNOE«aRAT�aN � qpp��CATION FOR PLUMBING PERMIT �1
I heieby,aff�rm rbot I hnve a certi(Ico�e of consenl ro sclf in- ����5 oP:J aie7 L �
7tAhp7A � �
sure,or o cerlilico�e of Werkers'Compensaiion Insurance,w a CE gv(REV.8i[i5� L�
cerr�f�ed cepy thereo((Sec.3800,Lab.C.)
voi��Y No.Z3bIC.QQ59�7.9966ny�ATTONWIDE COUNTY OF LOS ANGELES DEPT.Of PUBLIC WORKS
� Cerl�fied tepy is here.by{urnished. BU'!D"�G •
fC7 AFPIICANT TO F:��IN I,F31VT C�TYFE)
1-1 Cerlified copy is filed wiih the county builrling inspection :.CD'r;55 ����'j'
Ld depar�men�. '�U•.'DE2 FIXTL'R'CR iTE!.1 � FFF
LOCALITY
�a+e 9-1-88 APPr�o,,,NEW PLUMBING 3 WAiFR CIOSFT ITOiLEiI 6 Lg� DIAMOND BAR
r.=nc esr
BATfi TL'9 ceoss si. GRAND AVE.
CERTIFICATE OF EXEMr'TION FROM VVORKERS' 2 1Z
COMPENSATION INSURANCE cH0'.^.'R 121 C�����4 BRAMALEA LIMITED
(This saNion naed nol be complatad 11 fhe work involvsd hy ' t.��� --�� --�-"-��-�--� -��
tho pormit If for one hundred dollor�(3100)or lett.) lavnTORv aCCaFSS 1 ATRWAY AVF_ STiTTR N
I cerlify fha�in fhe periarmancr.ef the work for which!his prr- S�Nr
mit IS ISSUPd,I sholl noi emplay ony person in any manner so 2 12 C�fv COSTA MESA T;����`� 85�-1��1
os b becemr.sobjr.ct to the Werkers'Compenso��on Laws. 1 OISHWASNfR (I �
ccvrznne, W�I:IG—C4NTRA.�S
Da�e Applitont QOiHES Y/ASHER E1 ACCp'S5
NOTICE TO APPLICANT:I!,a(�er mo4ing this Cerhficafe o!E�- Z I�i 1 $. DUPONT DRIVE
r.r� +ion, oo sF.ould become sub'ecl lo ihe.VJorkers'Com en- SVJI.M VING COCL FECEPiCR
P Y I P C�TY iEL.h0.
salion provisions of�he lober Code,yau musl fcrthwi:h comp- :,q;;,..,ceq�.�,,;;o�y�,c.q I ANAHIEM 937-3972
ly wi!h such provisions or�his permit sholl be deer�e�l ravok- Si�,iE uC.
ed. V.�ATFR f1EA1ER IICFNSe 1:0 CLA55 —
IICENSED CONTRACTORS DECIARATICN 6 �'S*.��CT^:o rsC:[55ED 9r
I hereby o(firm iho�I am I�censed undr.r provisions oi Chap�cr GAS SvSiE!.t � CUilEiS //—�
9�commPncin�with$eciio�7000)el Division 3 r.f the Eusinesz Uu�tei50e•Ea �O — !�
1 s rcx srstt.�+ 1I SO V�ILIDATION
nnd Professiors Code,ond my license is in full force and ef- FINA N
fect. I DATE ./ � a
Ucense Number 476109 lic.Class C—"�6 �
U
I FINAL ^ ¢
co��«��o� NF.W PLU*1BINC�o�iP�31-$$_ I I BY �-^,�-� o
�
U
� I om exempi undrr Sec. I W
a
B.BP.C.ior this rrasan Plan check fee I ► 2
�O�'� PtUM�BING P[R.MIT ISSUI!`G FEE S 10I r)�
Si�na'ure TOTAL FEE
:G�2.u,.
SINGlE FA!.11LY Plan check npplicon� � '
NOME OWNE2-BUILDER�YLARATICN (. • • • a e `
I hereby oifirm thot I om enempl irom Ihe Contractor's Licens� Nome
lo•.v for fhn lollowing reason �Srclion 7031.5, 6usines5 a�d ��• � � :'•(,'('
Professions Code): A�idress
� Cii iel.No. � ' � I �-.i,.�O ii
I,as ownr.r o!ihe p�operty,will do thr.wr.ik a�d nc� Y
srrucrure.is noi int=nded or of(c�ed for sale(Sec�ian 704�, `1
Business ond Profess�o�s Ccde�. G C.� � —C`.3
. .
CCNSTRUCTICY LENDING AGENCY '
I h�rrby affirm Iho1 Ih�re is a to�shu[�ion lending ogency for -
�he perie�mence e(ihn work for which ihis permit is issued
(Set.3097,Civ.C.).
lender's Neme
Lender's ilddress
I cartify that i have�ead ihls opplicoiion and s�a'e ihat the �
above in(orma!�on is cerrect.I ogree io comply wiih all Couniy ,
ordinances ond S!a�e lows regulotfn�Plumb�n�,and hereby
ou�herize represen!ctives of this County to enter�pon ihe
above�mentioned praperly for inspection rposes. ,
� � �/� � SEE REVERSE FOR EXPLANATORY LANGUAGE '
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