HomeMy WebLinkAbout1180 DIAMOND BAR BLVD (10) .WORKERS'COMPENSATtONDECIARAiION APPLICATION FOR PLUMBING PERMIT {� ��
•. I hereby bf(`in that I have a cenificale of consent 10 self �6Ayb�q �
insurt;�or Lt_1ctificofe o1 Workers'Compensa�'ron Insurance, CE Bi7(REV.10/Bl) .
or e cenified copy thereaf($ec,38W,LGb.C.) � 'COUNTV OF LOS ANGELES BUILDING AND SAFETY �
. gwe 6nGZ�� Ni��.C,mias kr�: 4�
Po'cyNo. Company_� ..
Certified copy is herehy furnished.
❑. FORAPMICANTTOFILIIN(PRINTOR7VPEJ BUIlDING�.. i - '
Ceriified copy is iiled wi�h�he coumy bui�ding Inspec-. A�DRESS� D� • DX�D}� VA
IiondepartmenL � NUMBER FI%TUREORITEM (� FEE ����TY • '�.
Dote II'�S�� AppliSonISBL� WATERClOSET ryEAREST � - .
CERTIfICATE OF E%EMPTION FROM WORKERS' Ba1H TUB ��u ST• i-J - � ' � �
� �COM�ENSA710N INSUAANCE SHOWER OWNER � e��P - - �
(Tbl���tllen�n��d no1 b�tompl�f�d if fh�work Inwlv�d 6y �IL
fb�p�rmit Is lor on�hundr�d dollan(SI00)or le�s.) 3 LAVATORY (J'1) AppREu����� D/Qrya•j,� Q [X+v
� �I cenify that in the�performance o��he work foi which ihis
pe�mit is issued,I sholl nol amploy any person in any monner � � SINK Q�CITV -� D w TEL.NO. � �
K�
so as 10 become sobject ro the Workers'Compansotion Laws. DISHWASHER � � �
Da�e epplicont� QOTHES WASHER �TRACTOR G�QD�(/EQ �� ��1V�i4�'A
NOTICE TO APPLICANT: If, afler moking this Cer�iiica�e of ADDRE55 f�3� ��M c�M - . . .
' Eaemplion, yoo shoold bemme subjett lo fhe Workers' SWIMMINGPOpLRECEPTOR - .
Compensotion pro��sions of ihe Lobor COdC,you must forth- LAWN SPRINKLER SYSTEM CITY��i4P.dFa�(�J�/e TEL NO.�0 �7 1
wiih comply wiih such provisions or �his permit shall be
SSATE �iC. n /
,- deemedrovOked. � . ' WATERHEIITER � UCENSENO. 5Q�?ZO� CLA55 C-r�7G?
, " UCENSEO COMRACT6R$DEC[ARAifON . DISTRICT rr0. raOCESSeD BY
�I hereby oHirm�hof I am licensed under provisions of Chapter 9 / GAS SYStFM Z pUTLETS
. (commencing with Seciion 7000)of Division 3 of the 8�siness pU1lEi50VER � �' '
ond Profassions Code,ond my litense Is in full force and effacl, . 5 aER SYSiEM . ' FINA� VAIIDATION
License Nvmbar ��20� Lic.Class e�� � f L�L• S/�tl�(GS �ATF / � � � Q
3 � AQ/EltJS Q"'(� FINAL ' U
Conhacto�GAelk.e?�A�f��Da�e /L—S'�� BY
❑ I am e.empt under Sec.� O
8.8P.C.foi this reoson � �.���J-.�G A �U
Pfan check fee �
Da�e: -� ... � t1�3 • sarj N
PlUAhBlNG AERMIi ISSUlNG FEE S
Si9norure �V I • 1 7 2 5 0 z
TOTAL FEE � � . �
� Plan check applimnt - . .. ° + 1 7�2 5 0�
SINGIE FAMILY .
HOME OWNER-BUIIDER DECLARATION Name . f 1.O 5"8 7
1 bereby affi�m thot I om exempl from the Conhoctor's License� Address �
Law for the folfowing reason(Seclion i031.5, Ousiness and � � � � . - .. . .... .. ....... .__ .
Professians Code): Cit
❑ , Y Tel.No.
I,as owner of the property,will do the work ond the
shuc�ure iz not intended or of(ered for sale�SeUion �
70dG,Business ond Proiess�ons Coda). " �- �"- � - - �- � • �- � . . '
CONSiRUCTION(EN�MG AGENCY . �
. . . .. _. . . . . . . . .. _ ..... . .
�hereby nffirm that there is o canstruction lending agency for � -
ihe perfarmance ol ihe work fo�which rhis permi�is inoed
(Sec.3097,Civ.C.l. . . . . . . . -. . .
Lender'sName- �+�D.��. . . . . . ...- - -. ... . . . .
lender'sAddress �-�/�-��P - - -� - - � �-�- - -- � � � -
I cerli4y Ihal 1 have reod this opplication ond s�aie�hat Ihe- �
above iniormaiion is corrett.I agree to tomply wiih ali Coonly � � � '� - � -� • �� � �� � ..... ._ .
ordinonces and S�at�Iows�egulating Glumbing,and hereby
au�horize repre'seNorives of Ihis Counly lo enter upan the - - � . _ _.
obove-mentioned prope��y for inspeUion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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