HomeMy WebLinkAbout0801A (4) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I heheby,offilm ihat 1 have a certificote of consent to self im ��2�OPW 4�87 �
sure,or a cefti4icofe of Workers'Com ensa�ion Insuronce,or o �6A667A
P CE 817(REV.Bi86)
certiiied copy ihereof�Sec.3800,Lob.C.), - �� �
poGcy No.73WC005047�QQ,�(�„yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS',
� Certified copy is hereby furnished. ALS�H
FOR APPIICAM TO FILL IN(PRINT OR TYF'E) Bl11LDING -- � � �
� Ce�tifiedcopyisfiledwilhiheco�ntybuildinginzpection AD�RE55
deportment. � NUM6ER Fl%TURE OR ITEM @ FEE
iocnurv DIAMOND BAR
Date 9-1—HH qPP���a�,NEW PLLTMBING 3 WATER CIOSET(TOI�ET) 6 LH NEAREST .
� CERTIFICATE OF EXEMPTION FROM WORKERS' � 2 eatH iUe 1z cRoss sr. GRAND AVE.
� COMPENSATION INSURANCE OwNER '
2 SHOWER 12 BRAMALEA��LIMITED'-�
(Thi:��ttion nNd not bs eomplafsd lf th�work invelv�d by �y��
tho parmit is For ons hundred dollars(SI00)er I��s.) lAVAT04Y 24 ADDRESS 3151 AIRWAY AVE. SUITE N
I cerlify that in the performonce of the work for which this per- SiNK
mi�is izsued,I shall not employ any person in ony manner so 2 12 OTv COSTA MESA rei.No.850-1001
as to become subject to Ihe Workers'Compensalion Laws. 1 DISHWASHER 6 CONTRACTC
RIEW PLUMBING CONTRACTORS, INC
Da1e p,pplicant 1 CLOTHES WASHER 6 AD�RESS 2141 5. DUPONT DRIVE
NOTICE TO APPLICANT:If,oFler moking thi5 Cerlifim�e of EK- SWiMMING POO(RECEPiOR
emplion,youshouldbecamesubjet11o1heWorkers'Compen- ��T� ANAHIEM TE�.No.g37-3972
Salion provisions o(the Labor Code,you musl forihwilh cOmp- �qWN SPRINKLER SVSTEM
� ly with sach prorisions or ihis permit sholl be deemed revok- S�AiE liC.
ed. 1 WATER HEATER 6 ueeNse n,o.426109 CLA55 C-36
IICENSED CONTRnCTORS DECLARATION oisraicr NO, FROGESSED BV
I hereby atiirm tho�I om licensed under provisions of Chop�er 1 GAS SYSTEM 6 OuitETS ( /Q
9�commencing wilh Section 7000�of Divisian 3 of the Business OUTLE75 OVER
fe d Professions Code,and my license is in full force ond ef- 1 5 PER SYSTEM 1 50 F�NA�/ � �(l A��DaT��N a
DATE 7 0
License Number 426109 l�c.Closs C-36
U
FINAL Q
Comr000r NF.W PLUMRING Date 5-31-88 BY p
t-
� I am exempt under Sec. W
. B.&P.C.for this reasan . Z
Plon theck fee
�ale: PLUMBING PERMIT ISSUING FEE 3 LO SO
S�gnature � TOTAI FEE l i(� �Q �Q$Q I {`
SINGLE FAMIIY
NOME OWNER-BUILDER DECIARATION Plan check appliconl #_� � . e .J
I hereby affirm that I am exemp�from the Contractor's License Nome �
Law fo�Ihe following reoson(SeUion 7031.5,Bosiness ond � ° � � �:.�l Q
Professions Code): Address a . , ,� (;,C y,.T
� I,as owner of Ihe properly,will do the work ond the Ci�y Tel.No.
slructure is not intended or oFlered for saie(Seclion 7044, , �t�,�� I —(;8
Business ond P�ofessians Code�. , ►
CONSTRUCTION LEN�ING AGENCY �
I here6y affirm Iha�Ihere is a tons�ruttion lending agency for �
the perlormonce of the work for which�hfs permii is iss�ed
(Set.3097,Civ.C.). -
Lender's Nome �
Lender's Address �
I cer�ify thot I have read�his opplim�ion and state that the , ►
above Iniormaiion is correct.I a9ree�o comply with all Counly �
ordinances and Stole laws reguloting Plumbing,ond hereby ' .
oulhorize representatives of this Couniy 10 eMer upon the
above•meNioned property for inspection purposes.
� �� �—�i` SEE REYERSE FOR EXPLANA70RY LANGUAGE
5lgnoture f Permitte Da�e ��
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