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HomeMy WebLinkAbout1135A (5) �. WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT �`�/� /'by,offirm ihot I have a cer�ifico�e of consero m self 7gpg87A Ie,or a terlifito�e o1 Workers'Compensolion Insurante, CE 817(REV.8l88) �.ce���ied o �h e e f(Sep.3e��La6.C.� . �WC�B�l�� Hlqhlands InSUlance Co. COUNTV OF LOS ANGELES DEPT. OF PUBLIC,VIfORKS �IiEy No. � Compony - . . � . . . , Ceriified topy is hare6y furnished. � FORAPPLKANTTOFILUN(PRINTORTYVE) BUILDING ZZ92O Estoril Dr. Ceriifiad copy is filed wi�h the coun�y building inspeo � � �� ��o�d�����n� NUMBER FIXTUREORIIEM � FEE �����, �, Diamond Bar 8/26/87 p�atore Plumbing� IIl . WATERCLOSET 108 00 Da�e ' p�Som NEAREST j� CERTIFICATE Of EXEMPTION FROM WORKfRS' ],1� &4THTUB �6. 84 QO ��u 5T. . POLtO Grande Montefino . COMPENSATION INSURANCE 6 sNoweR . . . 6. 36 �� ��R I (Thi�iMion nNd eaf 6r compl�lyd if fh.work Imol��d br �'�� 17791 Mitchell South � fh�permll la fe�on�hundr�d dollan(SI00)or I���.) 24 LAVATORY qpp�g . � I cerify thn�in the performanca of�he work for which�his 6 6. 36 �0 Irvine � � 660-0660 _ � permit is issued,I iholl not employ any person in ony monner SINK CITY TEL.NO. . � So as lo become subject fo Ihe Workers'Compensolion Lows. DISHWASHER � 6. 36 �0 .. � corarancroa p�atore Plumbin InC. ' �e 4pplica�f ( CIOTHES WASHFR 6. 36 00 �-�.OTICE TO APMICANT: If, after mokiny this Certifitate of ���� �� �i' �+mp�ioa, you should become svbjed lo ihe Workeri - SWiMM�NG�00tRECFPTOR � qry Ontario Te�.r,o.985-5878 I F j�pensation provisions oi Ihe Lobor Code,you mus�fwth• LAWN SPRINKIfR SYSTEM . � i6 comply wi�h such provisioni or this permit shall be STaiE LiC. � �'deemad ravoked. � (� WATER MEATER 6. 36 00 �'�"�NO� 355068 ��C-36 � IICENSED CONTRACTORS DECLARATION � D15TRICT NO. VROCESSEU BV I hareby afiirm thof I am licensed under yovisions of Chopter 9 �SYSTEM OU7LE75 3 �0 � ^/y��1 O� (comme�+c�np wi�h Setlion�000)of Division 3 of the Business . OUilET50VFR �+ � 9' � ond Professions Coda,ond my liceme is in fvll face ord effecL 5 vER SvSiE/di 9• � FlNai . VALIDATION t7 � License Number 355068 i;�,�i,� C-36 DA � Amatore Plumbing, Inc. 8/26/87 FINAL d � Contraclor' Da�e BV h' v � ❑ I am ezempl under Sec. y. B$RC.for this reawn � 2 j Plan check fee � �,�: .'=1 1 3.5 A I . . �� 7LUMBING�ERMIT ISSUMG FEE S Signoture � • • e • •5 TOTAL FEE $']1 $0 Plan check applicant , '�7 1•S O ��� 1 � SINGIE F,4MILY . . • •�'J�,5 Q� � J HOAAE OWNER•BUILDfR DECLARATION Nome � �i.�.�Ey�wp....�tia!!a�.,,�TPr{...,.�r1.��....y�.��%�i�.ense !1 n?R—R 7� ;far�he followi�g reason(Sec�fo�7031.5,B�si�efs ond Addreas � euions Code): ���y ' Tel.No. ❑ .I,os owner of the proparty,will do 1he work ond Ihe svudure is not iroended or oHered for sala (Section . � . � 7041,Businass a�d Professions CodeJ. � . CONSTRUCTION LENOING AGENCY - - - � .� - � � I hereby oHirm that there is n cons�ruction lending ogency for Ihe performance of Ihe work for which ihis permil is isaued - - � � -� �- � �� �� � � � - � ��� � (Set.3097,Civ.C.). lender's Nome - . lender i Addross - - � I ce�ti/y thot I hove read�his opplication and sla�e ihof the , � � o6ove inio�motio�is tarect.i agree�o comply wi�h oll Counly o�dinonces and Sb�e laws regularing P�umbing,ond hereby � � � � � au�ho e present tives o1 this County to enter opon the ob e=m ioned r perry for inapeUion purposlt. SEE REVERSE FOR EXPLANATORY LANGUAGE L Sign e of ermillee Dol ' , . I �I T C � +� S Gl Gl �� C . . . . . . � � Nc J �M = j C -Vi � vi C p ' m y� < .: Q 1 � 9 � � . , i ; ..1 .. .�� �.I r�I �J vl Tl I~n -1 7 � t n r ' . � _.. I ; �'�I T:•' _ :p � �1 f= ` T _. . . � � i� 7 . T� . � . . . . ; � . (�'� i , U ! ?r 2 I �_ . 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