HomeMy WebLinkAbout0807A (4) WORKERS��oMPENSAT�oN oE��ARAT�oN � APPLICATION FOR PLUMBING PERMIT
I here6y,afiilm ihat I have o certiiimle of consenl ro self in• p"�6 DPW 4iB7 f�
suie,or a te'r�ificate of Workers'Com ensarion Insurance,or a �����
P CE 0V REV.BiBC) � �
certified topy thereoi(Sec.3800,lab.C.) � L� �
Policy No 73WC005047��}��TATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS'
� Certified copy is hereby turnished. LOT PLAN:2�i � ' T�CT: �
FOR APPIICANT TO Fllt IN(PRINT OR TYPE) 6UIlDING �
� Cer�ified copy is filed with ihe coun�y building inspec�ion nDDaES 4 SOUTH SUNNYHILL PLACE
depar�menl. NUMBER F�XTURE OR ITEM (d fEE �OCAIITY
� Da�e9-1—$$ � Applican,�EW PLiJMBING 3 WATERCtOSET(TORET) 6 iH NFARESi DIAMOND- �� �
CERTIFICATE OF E%EMPTION FROM WORKERS' Z B.4iti TUB 12 ceoss sr. GRAND AVE.
� COMPENSATION INSURANCE. � �1 SHOWER 6 OWNFR I I
(Thb utilon ne�d noT bs compl�l�d if Iha work inrolvsd 6y MAIL -
ths p�rmil is for one hundrod dollara(f100)or las�.) 4 LAVATORV • � 2(; ADDRESS 3151 AIRWAY AVE. SUITE N
1 certify Ihof in the perfarmance oI the work for which Ihis per- SiNK �
mit is issued,I sholl nol employ any person in any monner so Z ' 12 °TV � COSTA MESA TEL.NO.$SO—lOOL
as to bemme subject to the Workers'Compensauan Laws. 1 DISHWASHFR ( CONtRaCi
°REW PLUMBING CONTRACTORS INC.
Date App�icant 1 CLOTMES WASHER 6 A�DRE55
NOTICE TO APPLICANT:I(,afler moking this Certifitote of Ex- SW�MMiNG POOL RECEPTOR 1 PONT RIVE
empteon,yo�should become s�bject lo the Workers'Compen- CiTv TEL,NO.
selion previSionS af th¢Lobor Code,yo�mvst forlhwilh comp- �AWN SPRINKIER SYSTEM ANAHEIM — 72
ly wifh such provisions or this permit shall be deemed revok- SiATE IIC.
ed. ,,1 WATER HEATER 6 IICENSE NO. CLA55 —
� �- LICENSfD CONTRACTORS DECLARATION DISTRICi NO. PROCESSED BY
I hereby oHirm that I am licensed under provisions of Chopter 1 GAS SVSTEM 6 OUTLETS 6 �O
9(commencing with Seclion 7000)of Division 3 of the Business OU1LEi5 OVER
and Professions Code,ond my license is in full force ond ef- 1 5 PER SYSTEM 1 5� FINAL ALIDATION �'
ieU. DATE I'Z�'��� a
ticense Number 426109 tic.Closs C-36 a
i ' � FINAL /�� � U
� Co�nacfor NEW PLUMBING pare 8-31-88 ev �5�� O
{ � I om eKempl under Sec � V
� W
� B.BP.C.ior ihis ieason y
r Plan check fee , Z
Date: p�UMBING PERMIT ISSUING FEE 5
Signature
� � TOTAL FEE lOH QO �Q�Q I P�
� SINGLE FAMILY
FIOME OWNER-BUILDER DECLARATION Plon che�k opplicont . �� � � ' � 5
� I hero6y aHirm ihat I am exempl irom ihe Contmctor's License Nome
law for 7he following reason(Section 7031.5, Business ond � " � ��i.(j U
Professions Code): Address
� I,os awner of the proper�y,will do the work ond the Cily Tei.No. � � 1 C��'�% V
shucture is not intended or offered ior sale(Sedion 7044, . ��� � —�8
Business ond Professions Code). ,
CONSTRUCTION LENDING AGENCY �
1 hereby offirm thof there is a consbuction lend�ng agency(or - _ �
the pertarmonce af�he work fw which ihis pe�mi�is issued � _ �
�Sea 9097,Civ.C.). . .
lender's Name
lender's Address • '
I certiFy ihol I hove read Ihis applicolion ond stale Ihal Ihe �
above informa�ion is correcl.I agree�o comply wi�h oll Counry � ►
o�dinances and Slale laws regoloting Plumbing,and hereby �
auihorize representatives of ihis County io enrer upon ihe �
ve- qMioned property far inspeclion�uipose�
� x� SEE REVERSE FOR EXPLANATORY LANGUAGE
—«—
Signature of Pe�mi�tee Date
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