HomeMy WebLinkAbout0806A (4) WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT
I heie6y,aNifm 1ho1 I hove a certificate of mnsent lo self in- �-�6 DPW 4i87 �
oroceitificoreoiWorkers'Com enso�ionlnsurance,ora �bA��A
Sure, P CE B77(REV.8/BC) �
cer�ified copy�hereof(Sec 3800,tab.C.) �- �
Pol+cy No.73WC005047�(}n�IdATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Cernfied copy is hereby fumished. 6Un�iNG • •. 4Z
FOR APPIICANT TO FILL IN(PRINT OR TYPE�
� Certifed mpy is filed with the munty building inspeUion nooRE55 946 SOUTH SUNNYHILL PLACE
deparlmenf. NUMBER FI7(TURE OR ITEM (� FEE .
LOCAlI7Y DIAMOND..BAR .. .
Da7e 9-1-88 Applicon�EW PLUMBING 3 WATERCL05E71TORET) 6 1$ NEneFSi
� BATH TUe CROSS ST. GRAND"AVE. �����'
I CERTIFICATE OF E%EMPTION FROM WORKERS' 2 � I.Z
COMPENSATION INSURANCE StiOWER 12 ONINF¢ B�j EA LIMITED
(This�acfion need nof b�complated il tha work inrolr�d by Mpii
th.p�rmif is For ons huedr�d dollon(5100)or I»�.) wvntORv � Z nDDaE55
I cerfify Ihol in Ihe performance af Ihe work for which this per- SiNK
mit is issued,I sholl not emplay any person in any monner so Z 12 aTv -COSTA MESA 1EL.NO.HSO—LOOL
as fo become subject to the Warkers'Campensation Lows. 1 DiSHWASHER 6 CONTRACT
Dale Appli�ont � CLOTHE$WASHER PL I CONTRAC RS IN
NOTICE TO AVPLICANT:If,after making ihis Cerlifimte af Ex- 6 ADDRE55 Z1(+1 $. DUPONT DRIVE
emp�ion,you shou�d become sobject�o the Workers'Compen- SWIMMING POOI RECE9TOR
wiion provisions of the labo�Code, ou must forthwiih cam CiTY �AHIEM rE`."0.937-3972
Y P" IAWN SPRINKLER SYSTEM
ly with soch pro�isfons or ihis permit shall be deemed revok• STnre uC.
ed. � 1 WqTFR HEATER 6 ucen,se No.426109 CLA55 C-36
UCENSED CONTRACTOR$DECLARATION DISTRICT NO. PROCESSED BY
I hereby oftirm that I am licensed under provisions of Chapter GAS SYSTEM OUTlETS 6 j D
9(commencing with Sec�ion 70D0)of Drvrsion 3 af rhe Business OUitEiS OVER 1 5�
and Proiessions Code,and my license is in full force and ef- 1 5 PER SVSiEM FINAL ALIDATI�N >"
fect. DATE l—Z�`(��
License Number 426109 lic.Cless C-36 a
O
U
� FINAL �
Contracior NEW PLUMBING Daie $-31-88 BY p
r-
� � I am exempt under Sec. . W
a
B.BP.C.for this reason , ul
Plan chetk fee Z
Dare: pLUM81NG PERMIT ISSUING FEE 5 1O SO
$ignoture TOTAL FEE
114 DO �08Q6A
SINGIE FAMILY
NOME OWNER�BUILDER OECLARATION � P�on theck oppliconl $' � � � J
• o
1 hereby offirm thai I am exemp�{rom the Cemmc�cr's Li:ense Name
law ior�he following reason(Section 7031.5,Business ond � e � 1 [_��,�
Professions CodeJ: _ Address
• w � � ��V li_
� I,os owner of the property,will do ihe work and tho City Tel.No. �
shucture is not iNended or oftered for sale�Settion 70ea, p�+ � 1 —�� _
8usiness and Professions Code). " .
CONSTRUCTION LENDING AGENCY � �
I hereby offirm thaf ihere is o canstruction lending ogency(or . �
the perfo�mance oi�he work for whfch this permit is issued
(Sec.3097,Civ.C.).
lender's Name I
Lendei s Address '
I tertify�hal I hove reod�his applicalian and s�o1e thaf Ihe ► ,
obove informotion is correct.I agree to mmply wi�h a�l CouMy
ordinonces ond State lows regulating Plumbing,and hereby � �
a�ihorize representotives of this County to en�er upon the
obove-maNioned properiy for inspedion purposes. -
�_��F-�— SEE REVERSE FOR EXPLANATORY LANGUAGE
Signaf of Permitl Dole .
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