HomeMy WebLinkAbout0813A (4) WORKERS'COMPENSATIDNDECLARATION APPLICATI�N FOR PLUMBING PERMIT /--I
I heteby,oHitm iho�I hove a certiRco�e of consen�ro self in• p-��b DPW ei87 L '
76A667A �
5oie,or a cerfificote o4 Workeri Compensaii0n�nsurpnce,ar o �E 817(REV.Bi85)
certified mpy Ihereof(Sec.3800,Lob.C.) .
Policy No.73WC005047�QQ�(�yNATI0N4TIDE GOUNTY OF Lp5 ANGELES DEPT.OF PUBLIC WORKS
� CerHfied copy is hereby fumished. I.0'L PLAN:25 . TRACT: 2 �
fOR A7PlICANT TO FILL IN(PRINT OR TYPE� BIJILDING
� Certitied mpy is fHed wuh the couniy bwlding inspection aooaEss961 SOUTH SUNNYHILL PLACE
dBparfinenl. NUMBFR FIXTURE OR IiFM @ FEE �OCAIITY �
�are9-1-88 Applicon�lEW PLUMBING 3 WATER CLOSET(TOIlEf1 6 18 NEaeesr DIAMOND BAR
BATH TU8 ceoss sr. GRAND AVE. � •
� CERTIFICATE OP EXEMPTION FROM WORKER$" 3 IH
COMPENSATION INSURANCE 1 sNoweR 6 OWNER g�p�LEA LIMITED
(Th(s�Mlon na�d not bo compl�f�d if th�work tnvelvod by Mnit
th�p�rmlt Is for ono hundr�d doilars(SI00)or i�s�.) 4 tnva.roav 24 ADDRE55 3151 AIRWAY AVE. SUITE N
I certify Ihot in Ihe performance of the work for which this per- SiNK �
mit is issued,I sholl no�employ any person in any manner so 2 12 ��TY COSTA MESA TEL.ND.$SO—LOOL
� as ro become s�bject to rhe Worke�s'Compensarion LGwS. DiSHWASHER 6 coNTRncToAIEW PLUMBING CONTRACTORS, INC
Dote � Applicanl 1 CLOTHES WASHER (j
NOTICE TO APPLICANT:If,ofrer moking ih�s Certifica�e of E.- ADDRE55 Z141 S. DUPONT DRIVE
emption,you shou�d become subjetf to the Workers'Compen- SWiNNninlG POOL RECEP70R CIiV TEI.NO.
solion provisions of Ihe LabOr Code,you musl forlhwith comp• �AWN SPRINKLER SYSTEM ANAHEIM 937-3972
ly wifh such provizions or ihis permit shall be deemed revak- STATE LIC.
ed. 1 WA7ER HEATER 6 ueeNse No.426109 CLASS C-36
IICEN$ED CONTRACTORS DECLARATION DiSTRiCT NO. PROCESSED BY
I hereby aitirm thot I am licensed under provisions o(Chop�er GAS SYSTEM 6 OUiLETS 6 ��
9(commencing wiih 5ection 7000�of Division 3 of the Busine:s 1 OU�TRESyOEEM,R 1 5�
and Professions Code,and my license is in full(orce ond ef- FINAL '�l ALIDATION }
fecl. DATE� � a
Ucense Number 426109 Lic.Class C-36 �
U
FINAL �
Cono-ocror NEW PLiTMBING_Dme �-31—SS BY O
�
� U
I am exempt under Sec. I w
� 8.8P.C.for�his reason a
Plan check fee , Z
Do�e: PLUMBING PERMIT ISSUING FEE 5
Signoture - TOTAL FEE 11(y �� -:C!� (.J!3
SINGLE FAMIIV Plan check opplicanf �• • • e o J
HOME OWNFR•BUILDER DECLARATION
I hereby affirm ihor I om e.empt irom�he Con!roctei s License Name - �
Low for the following reason(Section 7031.5, Business and � • � � lJ.Q(� .
Protessions Code): Address ..
� I,as owner o��he properly,will do the work and the City . Tel.No. � ° , , ('�'J J� •
srructore is not intended or o((ered for sole(Secnon 7044, . ��,� � —i3�j
Business and Professions Code). � ► '
CONSTRUCTION LENDING AGENCY - � -
I hereby offirm ihor there is a consfrucfion lending agency for ,�
�he per}ormonce of ihe work ior which this permil is issued � -
(Sea 3097,Civ.C.). �
lender's Name •
lender's Address � ,
I certify that I ho�e read rhis opplico�ion and slate Ihof fhe
above information is correct.I ag�ee lo comply wilh all County ,
ordinonces and Stote laws regubling Plumbing,and hereby � �
avthorize representotives of ihis County fo enler upon�he �
a ve-m qlianed property for inspeUian purposes. � �
� �',�,�� SEE REVERSE FOR EXPLANATORY LANGUAGE
SignoNre of Permitfee Da1e
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