HomeMy WebLinkAbout1298A (27)WORKERS' 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,N05075288Company Farmers
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
Date 712185 Applicant P - R - 0 - Plumhj.ng
CERTIFICATE OF EXEMPTION FROM WORKERS'
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
TICE TO APPLICANT: If, after making this Certificate of
nption, you should become subject to the Workers'
�mpensation 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 Number 443774 Lic. Class C-36
Contractor P.R.O. Plumbin Date 7/2.1$5_
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
eby affirm that I am exempt from the Contractor's license
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.
r-
ign t6re—o Per i fee D to
76A667A
CE 817 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS
1415 S. S t e
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
Diamond Bar
WATER CLOSET
a
NEAREST
CROSS ST.
BATH TUB
(mfr)
OWNER
Bramalea Limited
SHOWER
LAVATORY
F f
MAIL
ADDRESS
3151 Airway Ave., Ste. N
SINK
�.
C�
CITY
Costa Mesa TEL. No. 850-1001
DISHWASHERJ/
(
CONTRACTOR P.R.O. Plumbing
CLOTHES WASHER
l'
ADDRESS
4418 E. Chapman
SWIMMING POOL RECEPTOR
CITY
Orange TEL. NO. 630_8441
LAWN SPRINKLER SYSTEM
ATE
5 CE NO.
LIC
443774 CLASS C-36
WATER HEATER
z)
DISTRICT NO.
PROCESSED BY
GAS SYSTEM OUTLETS
�j d
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE Z� VAL`IDATI®N
FINAL
BYa c
0 r C1
Plan check fee
PLUMBING PERMIT ISSUING FEE $f�J
TOTAL FEE
89�J_
Plan check applicant'
eress
r
Tel. No.
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
TLUTING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
FINAL
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
I hereby affirm that I cm exempt fiorn the Controcror'
License Law for the following mason (Sac-Ifor, -IJ31.5,
Business and Professions Code): Any city or counlyvlhich
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its issyance, also re-
quires the applicant for such permi0c, file a signed State-
ment that lie is licensed pursuant to the provisions of
he
Contractor's License Low (Chapter 9 (commencing v,,01i
Section 7000) of Division 3 of the Business and Pro I rcs _
sions Code) or that he is exempt therefrom and the basis
for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars (,$500).:
F-1 1, 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 C Yc-
for'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 w
improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did
not build or improve for the purpose of sale.)
I am exempt under Sec.