HomeMy WebLinkAbout0810A (4) "'°RKERS•`°""'E"SAT'°"°E""RAT'°" qppLICATION FOR PLUMBING PERMIT
I hete6y,affirm that I have a cer�i(ica�e o(consent to self in- �A��A�ais� . �
sure,or a cerli(imte of Workers'Compensalion Insura�ce,ora CE 817(REV.9ie6�
tertified copy thereof(Sec.3800,Lab.�C.) �
Policy No.7 W�79B�yNATIONWIDE _ COUNTY OP LOS ANGELES DEPT.OF PUBLIC WORKS
� Certified copy is hereby furnished. . BuitDiN� • '- ' • �Z
FOR APPlIC.4NT TO FILL IN�GRINT OR TVPE) qppRE55
� Ceriified copy is filed with the coumy building insped�on 970 SOUTH SUNNYHILL'PLACE
deporlmenf. NUMBER FIXTURE OR ITEM (i fEE �OCAtITV •
l Do�e 9-1-88 ApplicaniNEW PLUMBING ,3 WATERLIOSET�T04ETl 6 I$ NEARFST �
� CER7IFICATE OF EXEMFTION FROM WORKERS' BATN TUB 12 CROSS ST. jjAj�D VE �
COMPENSATION INSURANCE SHOWER OWNER
� (This��ction ne�d nof be compisfed if fhs work involv�d bY h�ail
IM�parmit it for one hundred dollar�(5100)or lef�.) LAVATORY ADDRFSS
I cerfify that in�he performonce of ihe wo�k ior wh�ch ihis per- SiNK
mi�is issued,I sholl not employ any person in ony manner so 2 12 C�rv COSTA MESA TE�.Na.HSO—I OOL
os to became subject to ihe Workers'Compen5ation LawS. DISHWASHER
. 1 6 CONTRACTO
Date Applicant CLOTHES WASNER AD�RE55
NOTICE TO APPLICANT:If,afrer making this Certifico�e of E.- SwiMrdlNG roOl R[CEP70R Z DUPONT DRIVE
emplion,yov shoold bemme subjeti ro thp Workeri Compen- GTY TEL.NO.
yplion provisions ol Ihe Labor Code,you m�si forthwith[omp- �AWN SPRINKlER SYSTEM ��I� 937-3972
ly with such provisions or fhis permit shall 6e deemed revok• SiATE LIC.
ed. WATER HEATER , LICENSE NO. CLA55 —
UCENSED CONTRACTORS DECIARATION DiSiRiCT NO. PROCESSED BY
I hare6y oHirm that I am licensed under provisions of Chopter GAS SYSTEM OUTlETS /�b
9(commencing with Seciion 700p)of Division 3 0(the 8usiness Oui�EiS OVEri � '
1 5 PER SVSiEM 1 50 p��DATION
ond Professions Code,ond my license�s in full force and ef- FINAL � Y
fect. _ DATE���-� a
License Numbar 4261n9 Lic Closs r-3F �
U
FINAL �
Conrrotlor NFW PT i1MRTNG Dare R-'t 1—RR BY ��� O
� � 1 am exempt under Sec. a
8.&P.C.for Ihis reason Plan check fee , y
z
Dote: pLUMBING PERMIT ISSUING FEE S I O SO
Signoture TOTAL fEE
SINGLE FAMILY Plan check applitaN ���1•0 n
HOME OWNER�OUILDER DEGLARATION _ .
I here6y aHirm�ho�I om erempt from Ihe Con�roc�oi s License Nome `�i � ' � _`�
Law for the fo�lowing reason�Sedion 7031.5, Business ond .
Professions Codej: Address � • � � �G�
� I,os owner of�he property,will do the work ond Ihe City Tel.No. • • � � ��.r ij T
. strutture is not intended or offered for sale(Secfion 7044,
Business and Professions Code). � ► " ��� T—��
� CONSTRUCTION LENDING AGENCY
I hereby affirm that the�e is a tons�ruUion lending agenty Por � �
the performonce of�he work for which this permil is issued
(Sec.3097,Civ.C.)..-
lender's Nome
Lendar's Address -
I certify that I have read ihis opplication and sra�e�hot ihe . �
obove in(ormation is correcf.I ogree 10 comply wilh all Gounty ,
ordinonces ond Stale laws regvloting Plumbing,and hereby ' -
aulharize rep�eseniotives of Ihis County ro enier upon Ihe �
obove•menlioned property for inspection p�rpOseS.
� ����� SEE REVERSE FOR EXPLANATORY IANGUAGE
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