HomeMy WebLinkAbout0811A I � -WORKERS-�oMPENSAT�oNOE��ARAT�oN � � qpp��CATION FOR PLUMBING PERMIT
i ZO-0076 DPW 4ie7 �
I'hereby,offilm�hot 1 hove a certificate of mnsenl ro self in- 76A667A
su're,or a ce�tificate ol Workers'Compensation Insurance,or a CE 817(REV.8�86�
I certified copy fhereof(Sec.3600,Lob.C.) - . � . �
i COUNTY OF LOS ANGElES DEPT.OF PUBLIC WORKS
Policy No73WC005047�n�1ATI0NWIDE
� CartiRed copy is hereby furnished. LOT PLAN:25 __, , TRACT:
I FOR APPIICANT TO FI��IN�PRINT OR TVFE) BUI�DiNG •
� Cer�ified copy is filed with the coumy building inspedion � FEE .aooeEss971 SOUTH SUNNYHILL PLACE
deporlmenl. NUMBER FIXTURE OR IiEM �Q�ALIiY �
WATER CLOSET(TOILET� DIAMOND BAR •
Da�e9-1-88 AppliconNEW PLUMBING 3 b 18 NEAREST
CERIIFICATE Of EXEMPTION FROM WORKERS' 3 BATH TUB 18 ceoss sT. GRAND�AVE: � -
COMGENSATION INSURANCE ' ' OWNER
1 SHOWER ' 6 BRAMALEA LIMITED
(This aecNon na�d�rof 6e complef�d if tha work involved by Mai�
th�perml�la fo�on�bundrsd dollors(5100)er las�.) (4 LAVATORV Zl+ ADDRESS 3151 AIRWAY AVE. SIIITE N �
I cerrify rhat in ihe performonce of the work for whkh this per- SiNK
mil is issued,I shall nol employ any person in ony monner so j2 CITv COSTA MESA TE��"a 850—L001
as to bacome subjeU to the Workers'Compenso�ion LawS. DISHWASHER 6 coNranaciiEW PLtJMBING CONTRACTORS, INC.
Dote Appli[ant 1 CIOiHES VJASHER 6 A�DRE55
NOTICE TO APPLIC.4NT:IF,o(ter makin9 this Cer�ifitate of Ex- SWIMMING POOL RECFPTOR 2141 �. DUPONT DRIVE
emption,you should 6etome s�bject to Ihe Workers'Compen• CITY TE�.NO.
wtion provision5 of Ihe Lobor Code,you musl iorfhwilh comp- �AWN SPRINKLER SYSTEM ANAHEI� 937-3972
�y wilh such provisions or rhis permil shall be deemed rPvok- ST�7E �i�_
ed. . WATER HEATER 6 uceNse n,o426109 CLA55 C-36
� IICENSED CONTRACTORS DfCLARATION, D6TRiCi No. vaOCE55ED BV
I hereby offirm�hvl i am licensed under provisions of Chop�er Gn5 SvSTEM OUT�E75 6 /D
9(commenting wilh Seclion 7000)of Division 3 of the Business OuilEiS OvfR �
( and Professions Code,and my litensa is in f�ll force ond ef- 1 5 PER SYSTEM 1 5� FINA� D� \/ LIDATION }
fect. DATE����j a
License Number_426109 Lic.Class r-36 �
U
co�vo�+or NEW PLUMBING oa,� H-3I—HH FINAL ,_� ¢
BY p
❑ H
I om ezempt under Set. I . W
a
s.av.c.fo.rn�s.eoson Plan check fee , N
z
� Dote: PLUMBING PERMIT ISSUING FEE 5
Signoture �
�� � TOTAL FEE 11[� ��
SINGIE FAMILY �
HOME OWNER-BUILDER DECLARAT�ON F�an check opplicam :"G II�,� �{
` f hereby affirm Ihot I am exempt from ihe CoNractor's License Name � � �
� Law for the followinq�eason(Sec�ion 7031.5, Business ond k^ •J
I Professiont Code): Address -
� ° � � 4.�1�
� I,-oz owner of the property,will do the work and�he ���Y Tel.No. '
structure is not iNended or ollered ior sale(Settien 7044, , • � � � (�,n(��
Business and Professions Code). , ► 0$ , 1 —��
ICONSTRLICTION IENDING AGENCY �
I he�eby affirm that Ihere is a mnsfruclion lending agency for "
the performance of the work for which this permif is issued � �
(Sec.3097.Civ.C.�. �
Lendei 5 Name
Lender's Addrass �
I cer�liy that I hove read this opplication end s�aie thot the - ,
above information is correc�.I agree to tomply wi�h oli Counfy
ordinonces and Sta�e lows regola�ing Plumbing,and hereby �
auihorize represenioiives oi�his Coumy m emer upon �he
abpve-me,ptio�openy for inspection purposes.
� /� 'g, �.�� SEE REVERSE FOR EXPLANATORY LANGUAGE
L
Signoture of Permitlee Date � �
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