HomeMy WebLinkAbout5058AWORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C. ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 690134 CompanyS-frJj e Fimd
7 - P 1 ex
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
h h b 'Id' ADDRESS 24 1 1 0 F_ . Sy 1 V n Glen (31 da 2
f l d
❑ Certified copy is i e wrt t e county ui ing inspec-
tiondepartment.
NUMBER FIXTURE OR ITEM
@
FEE
LAWN SPRINKLER SYSTEM
1-22-86
17 WATER CLOSET
.00
102.010
LOCALITY Diamond Bar
Date Applicant
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
9 BATH TUB `
54.00
CROSS sT. Go l den Springs D r .
COMPENSATION INSURANCE
2 SHOWER
.00
12.00
OWNER
(This section need not be completed if the work involved by
J.00
the permit is for one hundred dollars ($100) or less.)- .00 ADDRESS 1074 Park View Dr. ir201
I certify that in the performance of the work for which this 17
permit is issued, I shall not employ any person in any manner 7 SINK . 00 CITY �ovna TEL. NO.(J�`7—�j41
so as to become subject to the Workers Compensation Laws. 7 DISHWASHER D. 00 lJ
rnniro _ _
Date Applicant
"'VICE TO APPLICANT: If, after making this Certificate of
iption, 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 Number,408,303 Lic. Class C-36
ContractorbnllT.n LOC-
❑ I am exempt u der
B.&P.C. fcIK this rea
Signature
@, SIN LE F ILY
HOME ER -B IL
` D DECLARATION
Eby affirm that 1 exem om the Contractor's License
L. 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
7 CLOTHES WASHER
D.00
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
7 WATER HEATER
5.Go
7 GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
'+L . UU ADDRESS M Vine
CITY Riverside
STATE
LICENSE NO.408308
42.00 DISTRICT NO.
42.00
FINAL
DATE r24''
FINAL ,fir
BY
Plan check fee
PLUMBING PERMIT ISSUING FEE $ 1 6.50
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No,
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 on of this County to enter upon the -
ve- ntioned p ape ty f inspectioZ/p," oses.
SEE REVERSE FOR EXPLANATORYLANGUAGE
Sig ature of Permittee VaTe
TEL. No. 781-4561
LIC.
CLASS C-36
PROCESSED BY
■ 1.M.'"
nc.
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER 31 -AS WORK
ROUGH PLUMBING
7GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO, NOTIFIED
FINAL
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
I hereby affirm that I am exempt from the Contractor's
License Low for the following reason (Section 7031.5,
Business and Professions Code): Any city or county ,v"Vch
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 stok_
ment that he is licensed pursuant to the provisions of the
Contractor's License Low (Chapter 9 (commencing Y/Hh
Section 7000) of Division 3 of the Business and Pro(us-
sions Code) or that he is cxempi therefrom and the basis
for the alleged exemption. Any violation of Sc—tion
7031.5 by any applicant for a permit subjects the oppli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
El 1, as owner' of the property wilt do 'ilia work, and
the structure is not intended or offered for sale, -
(Sec. 7044, Business and Professions Code: The( ac-
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 safe. If, however, the building or
Improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he (lid
not build OF improve for the purpose of sale.)
I am exempt under Sec
B & P.C. for this reason-