HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (8) WORKERS'COMPENSATIONDECLARATION �ewasaw � qPPLICATION FOR PLUMBING PERMIT �7
1 hereby affirm that 1 have a certificate of consent to seR ce an(z•ao - y'
insure,or a cerlificate of Workers'ComOensation Insurance,or . � ��
a certified opy t reof(/S�ec.3800,La6.C.) � U
' (�����b �ew� COUNTY OF LOS ANGELES ' BUILDING AND�SAFETY
PnlicY No� anv � UIl l t . .. - � .
� C�rtired copy is hereby Nrnished. FOR APPLICANT TO FILL IN(PRINT OR TYPEI qDDRESS 1030 N: Gol den Spri ngs Dr
�Certified copy is filed with the rounty building(napection NUMBER �FIXTURE OH ITEM • FEE ,
de rim �� WATER CLOSET 68 0o LOCALITY Di amond Bar �
DatelSs���..Applicant����/��� �� NEAREST
� BATH TUB cRoss sr. .Hi h Knob.Road � �
CERTIFICA'IH Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE � SHOWER OWNER The Anden Grou
LAVATORY MAIL
[This secuon need not be completed if the work invoWed ADDFESS �1.
by the permit is tm one hundred doDars (f100)or less.) 7 SINK 28 0� CITY San Dimas TE�.No.599 6864 �
I certify that in ihe performance of the work fnr which lhis OISHWASHER �
p¢rmit is issued,1 shall no[employ any person in any manner CONTRACTOR P' �1 P i n � o
so as M become subject to the Warkers'Compensation Laws. � CIOTHES WASHER 'Z$ QQ A��RESS ' U
Date Applicant SWIMMING POOI RECEPTOR a �
NOTICE TO APPLICANT:If,atter�makin6 thls Certificate ot CITY TEL.NO. pf
GzempHnn, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE ' LIC. Z -
Cnmpensation provisions of the Labor Code,yov must for[h• LICENSE NO. CLASS C-36
v.•ith cnmply with such provisions or this permit shall be � WATER HEATER
deemed revoked. DISTRICT NO. PROCESSED BV
GAS SY5TEM fj OUTLETS 28 OO / �,�{ �
LICENSEDCONTRACTORSDECLARATION OUTLETSOVER 0 �i�7.O�JSCr�
I hereby aifitm that 1 am IicenSed under provisiona o(Chaptet 5 PER SVSTEM
v (commencing with Section 7000)of Divisinn 3 0[the Busi- - FINAL VALIDATION �
ness and Professions Code,and my liccnse is in tull force and DATE a/ �3
efFect.
!O
FINA
LicenseNumbet �42Z�4 Lic.Clau C-36 � av �
ContractorPipeline Plum�ing �/1�/82 �
� I am exempt from the licensing requirements as 1 am a Plan check tee 8 50 �
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
actin� in my D�ofesaional capacity(Sectlon 7051,Bus• �
iness and I'rofessions Code). TOTA�FEE 328 50
Lic.or Reg•NO. Date Plan check applicant
H04SE OR'NER-BfI1LDER DECLARATION Neme
1 hereby affirm that I am exempt from the Contracror's Address •
Lice�?e Lsi:•for the follox•ing rcason(Section.;03I.5,Busi- City Tel.No. �
ness and Professions Code): '
� l,as owner of the property,am exc�usively contrecting -
with licensed contrectors to construct the project
(Section 7044,Husiness and Professions Code). �
CONSTRUCTION LF.NDING AGGNCY � " �2 S b.�l A
1 hereby affirm that [here is a construetion IendinQ agency �
for the pedormanCe of Ihe work fOr whith this permif is �� � � �'�5
issued(Sec.3097,Civ.C.). � �
Lender's Name .
i •3zaso
LendePs Address
• •32fl50�
1 certify that 1 have read this application and state that the '
above information is correct.1 agree to comply with all Coun[y SHE REVERSF,GOR EXPLANATORY LANGUACE ��� `�+8 2 �
ordinances and State laws regulating Plumbing, and hereby ,
aut ize representatiees of this County to enter upon the
a -me on p o erty r ns ection p rposes./ �
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ignat e o rmi�tee Uate
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