HomeMy WebLinkAbout3542AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.0002910Hmpany CNA
Certified copy is hereby furnished.
Q Certified copy is filed with the county building inspec-
tion department.
Datel l % 7/86 Applicant /
CERTIFICATE OF EXEMPTION FROM WORKER '
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Numb
Li;,C;1I as Contract1/7/86
❑ I am exempt under Sec.
B.$P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
11 7 86
ignature of Perm' ee Date
76A667A
CE 817 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS 163 North Rock River Dr.
UMBER FIXTURE OR ITEM
@
FEE
LOCALITY
Diamond Bar
WATER CLOSET
NEAREST
CROSS ST.
BATH TUB
I
OWNER Edward WartehaMAIL
SHOWER
LAVATORY
ADDRESS 163 North Rock River Dr.
SINK
CITY Diamond Bar TEL. NO.861-0428
DISHWASHER
CONTRACTOR Nat Taylor & Sons Plumb.
CLOTHES WASHER
ADDRESS 8402 Katella Ave.
SWIMMING POOL RECEPTOR
CITY TEL. NO.828-0550
Stanton 90680
LAWN SPRINKLER SYSTEM
STATE LIC.
LICENSE NO. 136616 CLASS C.36
1 WATER HEATER 6.00
—
6.00
GAS SYSTEM OUTLETS
DISTRICT NO.
P CESSED BY
V L
OUTLETS OVER
5 PER SYSTEM
FINAL
�rVALIDATION
DATE ,
FINAL
BY
Plan check fee
PLUMBING PERMIT ISSUING FEE $
10.50
TOTAL FEE
16.50
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
FINAL dater oil gront
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
INSPECTOR'S MOTES
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Controclor's
License Law for the following reason (Section 7031,5,
Business and Professions Code): Any city or county which
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its issuance, also re-
quires the applicant for such permit to file a signed state-
ment that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Profes-
sions Code) or that he is exempt therefrom and the basis
for the alleged exemption. Any violation of Section
70.31.5 by any applicant for a permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
❑ I, as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Low does not apply to an owner of property
who builds or improves thereon, and who does such
work himself provided that such improvements are not
intended or offered for sale. If, however, the building at-
improvement
rimprovement is sold within one year of completion, the
owner -builder will have the burden of proving thot he did
not build or improve for the purpose of sale.)
I am exempt under Sec.
B & P.C. for this reason
0
Owner