HomeMy WebLinkAbout0804A (4) i WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
1 hereby,offirrn rhat I have o cerrificate of consent io self in- ����6 DPw 4ie7 �
sule,ar a certificoie of Wo�kers'Com ensation Insuronce,or a 76A66�A
P CE 817(REV.Bi86) �
I certified copy ihereof(Sac.3800,Lab.C.)
Policy No.74W!'O(15[1l.2iaAA(yiyTJAT70NWTnF. COUNTY OP LOS ANGELES DEPT.OF PUBUC WORKS
� Cerlified copy is here6y furnished. � '-` '
FO4 APPLICANT TO Flll IN(PRIN'f OR 1YPE) BURDING
r"7 Ce�lified topy is filed�with the county building inspection aooaess 928 SOUTH SUNNYHILL PLACE
�-74 deportment, NUMBER FI%TURE OR IiEM p FEE
. LOCALITY , .. ,..
DoteO—�—RR ApplicoMNF.W Pi.I1MRTN(: . WATERClOSETITO�tET) NEAaEST � �
BATH TUB CROSS ST. '
CERTIFICATE OF EXEMPTION FROM WORKERS' '
( COMPENSATION INSURANCE SHOWER ' Ov✓�ER EA LIMITED
(Thts�adion nNd nof b�complahd lf fh�werk involv�d by �i�
I 1h�p�rmil It for on�hundred doller�(5100)or latt.) tAVATORY nooeess 1 1 AIRWAY AVE. UITE N
I certify ihot in�he performonce of the work for which this per• SiNK
f mil is iss�ed,I sholl no�employ ony person in ony monner so CI7Y COSTA MESA TEI.Np.BSO—LOOI.
� as ro become s�bject to ihe Workers'Compensation laws. DISHWASNER
coNrancregEW PLUMBING CONTRACTORS, INC
Dote Applimnt � CLOTHES WASHER 6 ADDRESS
NOTICE TO APPLICANT:If,oiter moking this Certifitale of Ec- SWiM4�iNG POOL RECEPTOR
emp�ion,yo�should become sa6jeU to�he Workers'Compen- Giv TEL NO.
solion provisi0n5 of Ihe Labor Code,you must/orthwilh comp- (p,WN SPRINKIER SVSTEM �
ly wiih wch provisions o�Ihis permit shall be deemed revok- STATE �iC.
ed. WATER HE.4TER IICENSE NO. CLASS
IICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCFSSED BV
I hereby offirm ihat I om I�censed under provisions of Chop�er - GnS SVSiErn OUTLETS / �
9(commencing wilh Secrton 7000)of�ivision 3 of Ihe Busfness OuitETS OVER �
ond Professions Code,ond my license is in(ull force and ef- 1 5 aER SVStEh� 1 5� FINAL ALIDATION �'
feci. �L L'�
DATE a
License Number1F2610� ��c.Class C—'�6 V
FINAL �
NRW PT.iMR N(, p
Comrocto� Dme —31— 8 BY -
_ r
� I am exempl�nder Sec. V
W
B.BP.C.(or this reoson Plan check fee ► Z
Dote: PLUM8ING PERMIT ISSUING FEE S
Signature
TOTAL FEE 114 �O�O�l A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan theck opplitanl �i• t • :
I hereby a(firm Ihat I am eer.mpt from ihe Conlraclor's License Nome e
Low ior�he following reason(Seclion 7031.5, Business and � e � � U.Q�/
ProFessions Code): Address ' � ,� ' �. �J r
� I,os owner o(the property,wiil do the work and the City Tel.No. �
structure is not intended or offered for sale�SeclioN044, 0�� � —FS�i
�� Business and Prolessions Code). � �.
CONSTRUCTION LENDING AGENCY � - � �
I hereby affirm that Ihere is a conslrut�ian lending agency iar �
th¢performance of the work for which this pe�mit is issued ' _
(Sec 3097,Civ.C.J. .
Lenderi Nome
Lender's Address �
I certiTy that I have read thi:application and s�ate that the
above information is correcf.I agree to tomply with all Counly , �
ordinances and Stote laws regulating Plumbing,ond hereby
aufhorize representoiives of this County to enter upon ihe
o ve•m lioned property for inspection purposes. .
. �� g, 3_�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signai�ra of Permitiee Daie
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