HomeMy WebLinkAbout1370 VALLEY VISTA DR (52) WORKERS'COMPENSATION DECLARA7ION �A�� �P��CATIO[V FOR PLUMBI G,�PF�R�U1lT I
1ltereNy,iffirm thm t hove a certifiwte of consent to self in-
sure,or a certificote of Workeri Compensa�ion Insurance,or a �g 61 � n ^( , � �
cerhfie copy thereof{Sec.3800.Lab.C.j \Y� �Vl.'��
Polic�v.Q�Compony I�ODn CO Y F�ANGELES � i ��j6 p� .OF PUBLIC WORKS
� Certified copy is here6y 4omished. � _ `� ���
f ICAN I RI OR 1YPE BWLDiNG ' �r
�' Certified copy is filed with the co�nry building in cti n� � --- � �-- AD�RESS� � �� G V�,j%fJ /�/Z,,
de artment. NUMBER FIX7URE OR ITEM Q FEE LOCALITY �r
WASER CLOSET�TOILET) ND 1e«-
DGte App��cant . /�JT NEAREST
�,l�j�R�FICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 Si.
COMPENSATION INSURANCE - SHOWER OwNER/��BBO/� �r-pQ�FS
T Is sectton naod not bs comp�eted if tha work invpiv�d by ��t
c��
Iha pvrmil b Foi env hondr�d dollan(f100)ee fetf.) �P,vn10Rr aDDRE55
I tertify iha�in the performance of�he wark for which this per-
mit is issued,1 shall not employ any person in ony monner so � S��' Q"'[j CiTY TEC NO
as to become subject m ihe Workers'GompensaHon laws. DISMWASHER
CONTRACTO D�L/I����S' ��j.
Date App{imnl CLOTHES WASHER AD�RESS �O Qy,y �(��
NOTICE TO APPUCANT:If,nfter making ihis Certifim�e of Ea- SWIMMING POOL RECEPTOR
empfion,you should become subject to the Workers'Compen- CiTY �/
sation provisions of the Labdr Code,yDV-mu5f forlhwifh Comp- LpWN SPRINKLER SYSTEM ���1� T '��"
ly witb such provisions or this permu shall be deemed revok- SiqrE .y� LK. /7��
�' WAiERHEATER CICENSENO�`C���b CLASSL
IICENSED CONTRACTORS D€ClARAT40N DISTRIQ NO. PROCESSED BV
I hereby afirrm tkaf�am ticertsed under provlsions of Chapter Ga5 SVSFEM OUTtEFS
9(mmmencing wi�h Section 7000j of De��slon 3 of the Business OURETS OVER � �-�
and Professions Code,ond my license is in full force and ef- 5 vER SVSTEM � FINAL VALIDATION �'
fect. (� fy�
�.3 DATE `+' �tp � fi
License Nu Lic.Clau� ✓�/ � O
ml�C'� � FINAL I��" Q
Controtlo� Dafe 6Y d 0
� I am exempt under Sec. � � V
:-f�l=�.�i.� a
B.SP.C.for fhis reoson ptun check fee � _ Z
10 �2? • • V
� - Dasa: PLUMB(NG PERMIT ISSUING FEE$ '� t � "
Sfgnoture � Q
F TOTAI FEE 6 �� ` " I L'.;''`
SINGIE PAMILY -
HOME OWNER-BUILDER DECLARATION Plon check opplicont �� �� � . � .
I hereby offirm Ihat I am exempt fram the Cantractor's license Nnme " ��
� id c
Law for the following reason(Seclion 7031.5, Business and � ' �
Professions Code): Address �
� 1,as owner of ihe prope�ry, will do the wo.k and ihe <<4' Tel.No.
structure is nol intended or offered for sale(Section 7044,
Business and Professio�s Code). �
CONSTRUCTION LENDiNG AGENCY � - �
I hereby affirm ihai there is a canstructian lending agency for "
the performance of the work ior which this permit is issued '
(Set.3097.Civ.C.�.
Lender's Name
Lender's Address �
I certify that I have read this oppiication and state thot fhe �
above information is correc�.I agree to comply with all County
ordinances and State laws regulating Plumbing,vnd hereby
a��ize representatives of this County �o anter upon the .
pbov eN'6� p operty for inspection purposes.
� '� �� � �, ��� SEE REVERSE FOR EXPLANATORY LANGUAGE
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