HomeMy WebLinkAbout0800A (4) ' WORKERS�.�oMPENSAT�oNOE«ARAT�oN � APPLICATION FOR PLUMBING PERMIT {�
I he�eby,,aflirm thai i have a cerlifimte of consent�o self in- �A��A vW 4i87
surb,or a cet�ificote af Workeri Compensalion Insurance,or a CE SV(REV.Bi86) ' � . LJ
tertified copy thereof(Sec.3800,Lab.C.)
Pol�cy No.7'�WC00504xAQ�yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certified copy is hereby furnished. BUi�OwG
FOR APPLICANT TO Fllt W(PRINT OR TVPE) pDDRE55 q0
�} Cerl�ified copy is{iled wilh fhe county b�ilding inspection
`–� department. NUN'6ER F�XTURE OR ITEM @ FEE
LOCAIITY DIAMOND BAR
Do�e 9-1—RS qpPi��o�r�W PLITMBING 3 �'dATER CLOSET(TOIIET) (7 IH NEAREST � '
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BniH tue 12 CROSS Si. GRAND AVE.-
COMPENSATION INSURANCE � SHOWER - OWNER � LIMI�� '
(Thi�tscfioe naad nof b�cemplef�d if�h�wo�k inrol.�d 6y N,p,it
Ih�p�rmit is for on�hundred dollao(5700)or I�as.) 5 - t.4VATORV - 30 n�oaeSS 1 AIRWAY AVE. ITE N
I cartify thar in�he performonce of the�+ork(or which this per- SiNK �
m+�is�ssued,t shall not employ any person in any monner so Gtv COSTA MESA 'E` "o g50-1001
as to become subjett lo ihe Workers'Compensolion Laws. DISHWASHER
CONTRACTO ,
Dote Applicant 1 CLOTHES VlASNER 6 ApORESS
NOTICE TO APPIICANT:If,afler moking ihis Certificoie of Ex• Syyip,�N,iNG POOL RECEPTOR
emptian,you should become subject ro the Workeri Compen- GTv TEL.NO.
salion provisions oi�he Lobor Code,you must forthwNh comp- . tnwN SFRiNKtEe SVSiEM –
ly with such provis�ons or ihis permit sholl be deemed revok- STniE iiC.
ed. � 1 WATER HFATER 6 LICENSE NO. C1A55 _ I
. � IICENSED CONTRACTORS DECLARATION DiSTaiCT NO vROCE55ED 9Y .
I hereby ailirm that 1 am licensed under provisions of Chopter GAS SYSTEM OUiLEiS D
9(commencing with Section 7000)of Division 3 oi the Business Ol1TLETS OVER
and Professions Cade,and m �icense is in full forte ond ef- 1 5 PER SVSTEM 1 50 FINAL �'
y � VALIDATION
iecl. . DATE/� � n'
�License Number 426109 tic.Closs C-36 �
c>
FINAL �
con+�acto� NEW PLUMBING pa�� 8-31-88 ev o
U
� t am exempt undcr Sec. . d
B.sP.C.for rh�s�eoso� Plan check fee . ?
Da�e: PIUMBING PERMIT ISSUING FEE S :O s Q.C fi
Siqnature TOTAL FEE 114 �;• • • • •j .
SINGLE FAMILY Plon check applicant q
HOME OWNER-BUILDER DECLARATION I • � � 4.C O
I hereby offirm thol 1 am ezempt from�he Controctor's License Nome ' –
Law iar the following reason(Sec�ion 7031.5,Business ond � • ' � � �L ii l);
Professions Codc): Address ,
� I,as ownr,r o(the property,will do the work and the C��Y Tel.No. � O�.� � –L& i
stroc�ure is not inlended or offered for sale(Se�lian 7044, ,
Bvsiness and Proless�ons Codr.). ►
CONSTRUCTION LENDING AGENCY � � ,
I hereby affi�m tha��here is a cansrroUion tending ogenty for �
the performance o(the work for which ih�s pe�mit is iswed -
(Set.3097,Giv.C.�. , �
tender's Name � � ,
Lender's Address � '
1 certify ihat 1 hove reod Ihis opplication and sro�e that the ', , ,
-obove information is torretL I agree to comply with oll County �
�ordinances a�d State laws regulating Plumbing,and hereby • � � - - � � �
aoihorize represeNaiives af this Counly lo enter upon ihe - . �
a ve•me ioned properfy for inspecrio purposes. � �
�'3'8� SEE REVERSE FOR EXPLANATORY LANGUAGE
—Signature of Permittee �a�e � '
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