HomeMy WebLinkAbout1184 DIAMOND BAR BLVD (8) \1 `�
WORKERS'COMPENSATIONDECLARATION ' ��•�•�• � APPLICATION FOR PLUMBING PERMIT ,�7 �
1 hereby affirm ihat I have a'rertificate of consent to seif �, cc�n�x•�o � r�'
insure,or e certificete of Workers'Compensation Insurence,or , . ' � �� .
a certiCed co y thereof(& .3800,Lah.C.) U
��e'/v^/LS�O �l�� Cfr.vwrrS Z'�Vt COUNTYOFLOSANGELES BUILDtNGANDSAFETY
Policy No. Company
�Certified Copy is hereby turnished. FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILDING
❑ ADDRESS I /�A �
Certifled copy k filed with the county building Inspectlon � NUMBEH FIXTURE OR ITEM • FEE �
/� LOCALITY
1 �y���� WATER CLOSET V �/
Date�APPlicanl��5t"• NEAREST � (/
BATH TUB CHOSS ST. � '+— I',
CERTIPICATE OF EREMPTfON FROM WORKERS'
� COMPENSAT[ON[NSURANCE SHOWER � OWNER
LAVATORY MA��
(7'his section need not be completed if the work involved nooqe3s y7�Z wCC i �
�. by Ihe petmit is for one hun&ed dollars (5100)or IessJ ' }
. SINK CITY .='Y t NY �i{- TEL.NO. SS
( I certify that in the performence of the work for which this DISHWASHER � �
� permit is Itcued,Cshall not emptoy any person in any manner CONTRACTOH �f G� O � '
� so a5 to become subject to the Workers'Compensation Laws. CLDTHES WASHER A��RESS � U �
Date AppilCant SWIMMING POOL RECEPTOR W
NOTICE TO APPL[CANT:lt,after making thls CerHficate of CITY TEL.NO. n'
�
F.xemptinn, ym� chnulA hecnme suhiect tn the Wnrkers' LAWN SPRINKLER SYSTEM� gT,4T� �j _ LIC. ,/� Z
� Compensation provisions of the Labor Code,you must(orth- WATER HEA7ER LICENSE NO. J � CLASS �'J
with comply with such provisions or this permit shall be �ISTRIC7 NO. PHOCESSED BY
�deemed revoked. GAS SVSTEM OUTLETS Q ` /� 1��
� LICENSIiDCONTRACTORSDECLARATION OUTLETSOVER ``1 \�\� .
` 1 hereby affirm thet I am litensed under provisions of Chapter 5 PER SVSTEM
' 9 (commencing with Section 7000)ot Divislon 3 of the Busi- � FINAL VALIDATION '
.` ness and Wofessions Code,and my license is in full force and DATE �� �/ �
? effect. � . �
���,,p FINAL
�Licrnse Number3/��LLSL1_ Lia C�ass BV � � �
ContreetotT K C�1AS[� pate
� I am exempt from Ihe licensing requirements as 1 am a Plan check fee � . �
Iicensed arcfiitect or a registered D�ofessional engineer pLUM81NG PERMIT ISSUING FEE S - S� .
� - acting in my professionel capaciry (Section 7051,Bus _ .
iness and Professions Code). TOTAI FEE �, Q �
i
j Lic,or Reg.No. Date Plan chack applicant '
i HOME OWNER-BUILDER D@CLARATION Name . � �� �
�1 Merehy nffirm that i am exempt from the ContractnPs Addrn� y�� ' � w. �
License Law for the fotlowing reason(Section.7031.5.Bust• ��ty � Tel,No. SS�.^ �. y� �
ness and Professions CoJe): � � �
� I,as owner ot the property,am exctusively controcting � �
with licensed contrac�ors to construct the prnject �a��2 A
(Section 7044,Business and Professions Code). . .
CONSTRUCTIONLENDINGAGENCY � ������� ���5
1 hereby afCrm ihat therc is a construction IendinY agency � y • •' �5 0 '
Por the performance o!the work for which thie permit is . -
issued(Sec.3097,Civ.C.). - � ' � -
Lender's Name � • •�� �t Jr�c=i .
Lender's Address � O Cl D� —$��
�I certify that[have rcad this application and state that the
above intormation is correct.1 agree to eomply with all County � . SEE REV ERSE FOR EXPLANATORY LANGUAGE - �
ordinances and State laws regulating Plum6ing, and hereby �
authorize reD�esentatives of this County to enter upon 1he . � .
abov mentioned Droper tor inspeHion purposes. � � � �
� �. r'��� �/�I�/
ignature of Yermittee D e � �
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