HomeMy WebLinkAbout0814A (4) WORKERS'COMPENSATION DECLARAiION APPLICATIQN FOR- PLUMBING PERMIT
I heteby,offirm thot I have a certiiirote of consenl lo self in- 76A�2�ADPw eig7 /�
sure,oro ceilificote of Workers'Campensatian Insurance,oia CE BI7(REV.Bi86� I I
cerGfied copy ihereof(Sec.3800,tob.C.) � � LJ
Pol�cy No.73WC00504�.8�1�yNATIONWIDE COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Ce�tifled copy is hereby fumished. 63 . � 4zs�$
FOR APPLICANT TO FILI IN(PRINT OR TYPE� BUILDiNG
� Certifiedmpyisfiledwithihecounlybuildfnginspection nooaess955 SOUTH SUNNYHILL PLACE
deparlmenf. NUMBER Fl%TURE OR ITEM @ FEE _
i°�"tit° DIAMOND BAR
Date 9-1—$8 APPr,�a��NEW.PLUMBING 3 _ WATER CLOSET�TO�LET) 6 1$ NEAREST
BATH TUB CROSS ST.-�GRAND._AVE. . '
CERTIFICATE OF EXEMPTION FROM WORKERS' Z 1 Z �
COMPENSATION INSURANCE .L SHOWER lZ ownra BRAMALEA�LIMITED' ��
(This�xiion navd nof bs tompleled i(th�work involvad by MAI� '
tha p�rmh Is for on�Aundr�d dollors(5100�or I�st.) L4VATORY Z ADDRE55
I certify thai in the periormance ol the work for which Ihis per ,Z SiNK j 2 CITY COSTA MESA TEL NO.8SO—I.00 1
mil is issued,I shall no�employ any person in any monner so
as to become subject to the Workeri Compen5ation LOws. 1 p15HWA5HER 6 CONTRACTO
E IN C� T I
Do�6 - Applicanl ' � 1 CIOTHES WASHER 6 ADORESS
NOTICE TO APPLICANT:If,oher making ihis Ce�iifimle of Ex- 21G1 S. DUPONT DRIVE
em tfon, ou shoold became sub'ecr to rhe Workeri Com en- SwiMMMG POOL RECEPTOR
a r i c aTv ANp,].IIEM TEi."o.937-3972
sation provisions of the Labor Code,yoo must forrhwifh comp- � tnwN SPRiNKtfR SVSTEM
ly w�fh suth provtsions or this permii shall be deemed revok- STnie uC.
ed. , 1 WATER NEATER b l uceNSE r,o.426109 QA55 C-36
IICENSE�CONTRACTDRS OECLARATION DISTRICi NO. PROCESSED BV
I hereby affirm thot I om licensed under provisions of Choptcr GAS SYSTEM 6 OUTLETS 6 /D
9(commencing wi�h Section 7000)of Division 3 oi the Business OUitETS OVER 1 50 C
and Professionz Code,and my license is in full force and ef- 1 5 PER SYSTFM FINAL G/ ALIDATION a
fect. � . DATE�7/ /
Ucense Number 426109 u�.eioss C-3b �
FINAL V
Conimctor NEW PLUMBING Daie $-31-88 BY �
O
H
� I am eKempl under Set. . W
a
B.BP.C.for this reason Plan check fee , Z
Date: PLUM6ING PERMIT ISSUING FEE S lO SO
SignaNre
� TOTALFEE 114
SINGLE FAMILY �
. HOME OWNER-BUIIDER DECIARATION Plan check applimni ��Q��,[j a �
I hereby affi�m thot I am eremp�from rhe Contracror i License Name � r
Law(or Ihe iollowing reason($ec�ion 7031.5, Business and 1� ' � � 'J
Professions Code): Address
� � • � � :1.�'�
� I,os owner of the propeny,will do ihe work ond the �'�Y Tel.No. •
, siructure is nol intended or offered ior sale(Section 7044, . . ° � � �1,�J(j s
8usiness and Professions Code).
� . Ofll l —€3F3
CONSTRUCTION LENDING AGENCY
I hereby o(lirm Ihot lhere is a tonstruction lending agency for . �
the performonce of the work for which this permii is issued '�
�Sec.3097.Civ..C.). .
Lender's Name � . '
Lender's Address � .
I cerlify iho�I have read this application and s�ate�hot the ►
obove informa�ion is correct.I agree to comply with oll County
� ordinonces ond Slo�e�aws regulating Plumbing,and hereby
aulhorize representa�ives of this Counly to en�er opon the '
obove-menlioned property for inspection p�rposes.
� �_ �r 1/^�� SEE REVERSE FOR EXPLANATORY LANGUAGE •
Signol e 1 Permilt� Dale �
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