HomeMy WebLinkAbout0825A woRKERS•coMPeNSATioNOEc�ARAT�oN APPUCATION FOR PLUMBING PERMIT
I heieb,o thot I have a cerfifim�e of consent io self in- p-�26 DPW 4i87 f�
Y 4firm 76A067A '� �
s�re,or a certificate of Workers'Compensation Insurance,or a CE 817(eEv.Bi86) I I
certifled copy ihereof(Sea 3800,Lob.C.)' LJ
PoGcy No.73WC00504x(d9,�yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OP PUBUC WORKS
� Cenified copy is hereby turnished. . . .
FOR APPLICANT TO FILL IN�PRINT OR T77E) BUILDING .�
I"1 Certified copy Is ffled wf�h ihe county boilding tnspection nD�RE55
U� departmeril. NUMBER FIXTURE OR ITEM @ fEE �OCAtITY .
WATFR CLOSET(TOILET)
Daieq—l—AR Appl�m�iNF_W'PI,]AtRTNG G 18 NEqqEsr
BATH TU9 CRO55 ST. �j�jD AVE.
CERTIFICATE OF E%EMPTION FROM WORKERS' � LZ -
COMPENSATION INSURANCE SHOWER OWNER
(ThL ucllon nwd not b�compl�hd if tM work involvad by MAq
fh�p�rmif i�{er en�hundr�d dellars(LI00)or lafs.) �AVATORY 30 A�ORE55
I cer�ify Ihal in the performance of�he work for which this per- SiNK
mi1 i5 issued,I sholl nol employ ony person in ony manner so CI1Y TEL.NO.
az io bemme subject to the Workers'Compensanon laws. CO�STA MESA 8 0-1001
, pISHWASHER CONiRACTO
Dote Applicanl 1 CIOiHES WASHER 6 ADDRE55
NOTKE TO APPLICANT:If,after making ihis Certifica�e o4 En- SWIMMING POOL RKEPTOR
emption,yau should become subject�o the Wo.kers'Compern GTv TEL NO.
SOfion provi5i0n5 of ihe LobOr�OC�C,y0U mUS�forthWith Comp- �AWN SPRMKLER$VSTEM —
Iy with su�h provisions or�his perm��sholl 4e deemed re�ok- SiniE uC. �
ed. WATER HEATER IICENSE NO. CLA55
UCEN5f0 CONTRAQORS DECLARATION DiSiRiCT NO. PROCESSED BV
I hereby offirm ihot I am licensed under provisions of Chopter GAS SYSTEM OUILETS /O
9(commencing wilh Settion 7000)of Division 3 of Ihe Business DUTlEiS OVER
ond Professions Code,and my license is in full force ond ef- 1 5 PER SYS7EM 1 5� FINA �J ALIDATtON �
fect. - . DAT � ��d"�
License Number 426109 i��.cia5: C-36 a
O
FINAI V
Conrracror NEW PLUMBING oare 8-31-88 BY � °C
O
r
� I am exempt under Sec. � U
W
� B.BP.C.for this reason Plon CheCk fee ► _
Da�e: PLUMBING PERMIT ISSUING fEE S
� Signature TOTAL FEE ='O�7 J f{ '
� SINGLE FAMILY Plan check o limnt e • n
NOME OWNER-BUIIDER DECLARATION PP «° 'J
I he�e6y af(irm iha�I am exempt irom ihe Comroc�or's License Nome � • � I �,L�J
low far ihe fol�owing reason(Sec�ion 7031.5, Business and
Proiessions Code�: Address ,_
. . 1 1 �;��' ,.,
� I,os owner of rhe property,wil�do ihe work ond the Ciiy, Tel.No.
siruUure is not intended or offered for sole�Settion 704q �G.� � —�'O
Business and Professions Code�. -
CONSTRUCTION LENDING AGENCY � ► -
I hereby afFirm that ihere is a constrvctian lending agency for � � . - .
the performance af�he work for which this permit is issued �
(Sec.3097,Civ.C.). �
Lender's Name
Lender's Address
I certify�ha�I have read this application and stote that�he - �
obove informarion is correct.I ogree to mmply with all Coun�y ' ,
ordinoncas and State laws regulaling Plombing,ond hereby � �
aothorixe rapresentativas af fhis Coun�y 10 enter upon ihe �
abpG�•mep��e�erty for inspecii purposes. .
� �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signorure of Permitlae � Date . .
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