HomeMy WebLinkAboutNo Permit Number (1285)i
WORKERS COMPENSATION DECLARATION APPLICATION .FOR PLUMBINGPERMIT i jtt
hereby affirm that I!have a certificate of consent to self- 76A667A.' + L: jinsure'or a ce tficofe of!Workers',Compensat+on';Insurance CE 817(REV 1 ! II .: r-•.,I - ?1
ora terlif- d co thereof (Sec 3800,,1ob C) : j,, COUNTY OF LOS ANGELESf ) Ljlaf J 1 fl+ llf 1 .. :-.
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SUILDING AND SAFETY it'.I
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Cerfdred copy is hereby furnished - BUILDING
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Certified copy is filed with the county building inspec- 7t FOR APPLICANT TO FILL IN (PRINT OR TYPE! ! r F • i• ADDRESS,:1 t . - 011 `
I hon department. '' ,.
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NUMBER ;- j FIXTURE OR ITEM ' F4 FEE -.
7•;v IOCALffY I// /i!%/1
Dale '
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App; gent y.^A / (/L r i /•rt / I 'p' i+ WATER CLOSET! i +'
NEAREST ;
t CERTIFICATE OF EXEMPTION FROM WORKERSii BATH TUB ,°,, , I;,! '.f {' t J.,' CROSS ST./
COMPENSATION INSURANCE ",; !
This section rived not ba eomplvied 11 the work involved by rr SHOWER ! / _
OWNER l
PRESLEY CO .
thv permit is For one. hundred dollars (;100) or less) t at ;;l LAVATORY (':' r7• ii` MAIL. ... 4600 CAMPUS DRIVE
ADDRESS:'04IcertifyihaIIntheperformbnteoftheworkforwhchths ' 1
perm r is issued l !shall not employ,any person in any manner CITY ;' - _ : TEL. NO. VS i
I( so os to become•subiect, to the Workers ,Compensat on Laws _ (
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DISHWASHER ! C d•'` CONTRACTO AFEWAY PLUMBING '@ HEATING INC .'. i li
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ApPhcant• - t ' ' `i CLOTHES WASHER:'? I SII •.-,1 .-•'- ADDRESS •SANTA FE SPRINGS CA 1306 1NOTICETOAPPLICANT, i If, after, making this Certificate of i
Ezemplion, you. should become rsubjeCf to rhe Workers" r
1 I, aSWIMMINGPOOLRECEPTOR ! i +' CITY..,TEC NO 1
L1p Compensation provisions of the Labor Code ;you must forth ; ' Ikk 'I LAWN SPRINKLER SYSTEM I i i 4Ii Itl' F ' with. comply with- such',provlsions. or this _permit sholllbo I! il, STATE. J l ` LIC. it
LICENSE NO. A.i - %" %( `' / revoked ! .. .' I [ 1'1 p; WATER HEATER I Ili;% ;(y /,
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1 LICENSED CONTRACTORS DECLARATION
I hereby affirm lhati l om•licensed under prcvisions of Chapter 9- GAS SYSTEM / 'i l OUllETS : j' ? .0 i
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PROCESSED BY
commencing w,h,Section ,'7000) of,Diwsion 3 bf ;the Bus ness' SI I y pURETS OVER L VI ,t, f ribISPERSYSTEM -_ ' I I IE ./ and P ofessions Code, and my license is in full force and effect .I,
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FINAL ; OVAIIAT{ON
DATE IF VGi, Lic Class S r! l': r 1'7. %L ,_ 1 . WlicenseNumber
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fi1IamezemPlIunderSiSixrIi'.iY i
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B 8P C.Ifor this reason r Plan chi?Ck fee; 1'• L
a Date "I 1 + IF ;
jtIf. PLUMBING PERMIT ISSUING FEE S W
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SINGLE FAMILY t Plan Bir. ck appllcani '. >. •' •' i,i i•.
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HOME OVlNER-BUILDER DECLARATION j tName , j: , •. i. I r t Le e w
I hereby affirm fhoi am ezem t from the Contractor s Licensey ' pLawforthefollowingreason '(Section 7031.5, Business antl r Add•es•, t l :.
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1 't } i t'llll1 $1, e:. Professions Code) II ;
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owner of itis `
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e s'`' 3 Of 0 0 r; as the property,!will do the work and ;
structure i ( I' r is not intended or t6ffered for sale (Sr an i
I ' 7044Busine sand Professlons Code) I i,
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CONSTRUCTION LENDING AGENCY
I I he eby affirm that the eis a constriction lendmgagency tor,
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the performance of the wo k fo whichSec3097CivC) I I
lh s permit s ss ea
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r. l 1tLendersAddress'II .,} Il'jGIcertifythat'] ha a read ]his application and state That .the'
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ith all Court ycomplywf 'above informat on' isectcorrI o9ree,to cuPYh' a I l i
P ordinances and Slate.laws regulating Plumbing, and hereby,,.
of II! authorize representatives this County to ;enter upon
for inspection
the:;,! II'( -I4 P,II(:
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p; ! above-mentioned property purposes.%
j i f .:I + i 4 I SEE REVERSE FOR EXPLANATO Y LANGUAGE r 1 1
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T Signature of Permittee I f
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