HomeMy WebLinkAbout0802A (4) WORKERS'COMPENSATIONDECLARAiION APPLICATION FOR PLUMBING PERMIT
I hcheby,aifitm Ihal I have a terlifica�e of consent Io self in- p"��d DPYJ<i87 � '
sule,or a cehificote of Workers'Com ensation Insuronce,or a �6A667A
P CE 817(REV.8iB6) .
cerfiFied copy thereof(Sec.3800,Lob.C.) • ""' ,
Polky No.J3WCUOSO4Z(JB,Q(fiyNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS'
� Cert�f�ed co LOT51 PLAN:25 TRACT:42578
py is hereby fumished: BUaDiNG
� Cerriiied to Y 9� p FOR AP7lICANT TO FILL IN(PRINT OR TYPE)
py is filed with fhe counf buildin ns eciion NUMBER FIXTURE OR ITE�d FEE Aooaes�12 SOUTH SUNNYHILL PLACE
depo.imen�. @ iocauTr DIAMOND�BAR
ooie 9-1-88 npPi+co�rNEW PLUMBING 3 . WATER CLOSET(TOILET� 6 18 NEAREST
BATH TUB caoss st. GRAND�AVE.
� CERTIFICATE OF EXEMPTION FROM WORKERS' 3 LS
COMPENSATION INSURANCE 1 SHOWER - 6 OVJNER B�LEA LIMITED
(Thi�taclion naad noT b�compl�fed 1(fhe work involv�d 6y MAII
ths p�rmit is for on�hundrad dollurs(SI00)or I�s�.) (� LnvAroav 2(y nooaE55 3151 AIRWAY AVE. SUITE N
I ceriify that in the performonce oF Ihe work for which th�s per- SiNK
mit�s issued,I shall nm employ ony person in any manner so 12 ��r COSTA MESf1 TEL NO.$SO—lOOl
as to bacome s�6jetl lo the Workers'Compensauon laws. Di5HWA5HER
IcoNrzncTo�NEW PLiTMBING CONTRACTORS, INC
I Date Applicant 1 CLOTHFS WASHER (
AD�RE55
� NOTICE TO APPL�CANT:If,after making�his Certi(icate of Ex• SWfMMWG POOI RECEPiOR 2141 S. DUPONT DRIVE
amprion,you should betome subject�o�he Workers'Compen• UTv TEI.NO.
sation p�ovisions of the la6ar Code,you musl fo�thwith comp- � LAWN SPRiNKLER SYSTE�d ANAHEIM 937-3972
ly with suth provisione or�his permit sholl be deemed revok- STaiE uC.
ed. WATER NEATER IICENSE NO. CLA55 —
LICENSED CONTRACTORS DECLkRAT10N 1 6 �ISTRIQ NO. PROCESSE�BV
I here6y offirm thot I am licensed under provisions of Chap�er GAS SYSTEM OUTLETS �
9(tommencing with Section 7000)of Division 3 of�he Business OU7tEi5 OVER
fe�.Professions Code,and my license is in full force and ef• 1 5 PER SYSTEnn 1 5� fINAL � VALIDA710N a
DATE 2
ticense Number 426109 Lia Class G—'�C �
FINAL �---� V
Comroctor NEW PLITMBING pa�e 8-31-88 BY \� �
. o .
� .
� � I om ezempt under Sec. yVj
8.8P.C.for Ihis reason , tq
Plan check fee Z
Date: PLUM8ING PERMIT ISSUING FEE S �
Signarure TOTAI FEE
SINGIEFAMILY L1�i OO
HOh4E OWNER-BUILDER�ECLARATION Plan check opplicant ��C�n��
I hereby aifirm Ihat I am rxr,mpi from the Conhactor's license �,;ame �� � � � � �F
Law for ihe following reason(Section 703I.5, 8usiness and �
Professions Code): Address � ' � � ��C
� 1,as owner of Ihe properly,will do the work and Ihe Ciy Tel.No. • ° � � 4,�j Q�;
structure is not intended or of(ered for sale(Secfian 70.14, .
0usiness and Professions Code). ► ��.� �—?z
CONSTRUCTION LENDING AGENCY '
I hereby affirm Iho1 there is o mmlruction lending oqency for � �
Ihe pertormance of the work ior which�his permi�is issoed _ � '
(Set.3097.Civ.C.�. . . . . . .
Lender i Nome
Lender's Address
I certify that I have read this applicalion ond state thot Ihe ' , "
above informotion is correcL I agree ro comply wilh all County
ordinonces and Siate lawz regula�ing Plumb�ng,and hereby
authorize represento�ives of this Counry ro enter upon ihe �
ob ve-men'4ned property for inspet�� n purposes. • .
�' / ` .� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Perminee Dore
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