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HomeMy WebLinkAbout1180 S DIAMOND BAR BLVD (8) .WORKERS'COMPENSATION DECLARATION . 'vussv /7 � �1 hereby alfirm �ha� � he�e a'ttrtificate ofconsent to self �eem,=-.o, APPLICATION FOR PLUMBING PERMIT � . �insure,or a certiYcate of Workers'Compensatfon Insurance,ot . . �e certified copy thereof(Sec.3800,Lab.C.) ' � �p��� �15�66'$d Sta'tC f�b 1�d ; COUN7Y OF LOS ANGELES BUILOING ANDSAFETY��A Policy o. Company � � � i J � Certified cnpy is hereby furnished. - FOR APPLICANT TO FILL W(PRINT OR 7VPE) BU�LDING �I Q D S DI/�MO Na�iv�' BI � NUMBER FIXTURE OR ITEM • FEE ADDRESS O -, � Certified copy a filed with the county buiidinQ InaDection }7/ M O � ^ � �,'] � /� LOCALITV ��� �M Dateil�=�ApD��cantAa�'�'A P�PFi MBG� : f� WATERCLOSET NEAREST � � �Q D � 9ATH TUB cAoss sT. G R A N O • CER IFI A E OF EXEMPTION FROM WORKERS' � COMPEN5ATION[NSURANCE SFIOYYER OWNEH LAVATORY MAIL (Thie section need not be completed iP the wo�k involved � ADDRE55 } � by the permit is far orre hundred do�ars(5100)or leu.) g�NK a CITV � TEL.NO. Q (cettify that in the perfarmence o[Ihe work for which this �ISHWASHER U CONTRACTOR AQ 'P� ��C H � permit Ls isaued,I shall not employ any person in any manner . so as lo betome subjeCt to the Wotktts'Compena9tion Lawt. CLOTHES WASHER ADORESS''3 7 Z W y�M w�' � {'� , O ; �ate ADO�icanl SWIMMING POOL RECEPTOR V : NOT[CE TO APYLICANT:It,after making this Certificate of � CITY j;�N o,,p.r 6� TEL.NO.�,�-�r 3 d ; Exemp[ion, you should become subject to the Workers' LAWN SPRINKLER SVSTEM STATE LIC. N Compensation provisions oF the Lahor Code,you muet forth• �ICENSE NO.�!'S6p 3l CLASS �3 6 � J with comply wi�h such provisiom or this Dermit�shell be WATER HEATER deemed revoked. GAS SVSTEM OUTLETS DISTRICT NO. PROCESSE�BV � LICENSED CONTRACTORS DECLARATION OUTLETS OVER ` O �IAXO��J� � I hereby eH'vm that I am licensed under provisions of Chopter 5 PER SVSTEM ' 9 (commencing with Section 7000)ot Division 3 of the Busi- -- - �� � �� �-� � ���� _ " VALIDATION FINAL ness and!'rofessions Code,and mY license is in full force end 2� ReoF-C ra� DATE �a 3 �i� ef(ect" FINA 2S6o31 36-�{Z-3�I � License Number L(c.Cleu BV Contracto�4�A P�P� Dele r��� va I � ��"�Q Plan check fee { I am exemp! from the licensing requiremen s'�Yoam a f licensed architect or a registered profeasional engineer pLUMB�NG PEHMIT ISSUING FEE$ � 'acting in my professional capacity(Seclion 7051, Bus- iness and Professions Code). TOTAI FEE � � 1 Lic.or Ree.No. Date Plen check aPPlicent Nam� � HOA7E OWNCR•BUILDER DECLARA710N �I Addrms 1 hereby affirm that I em ezempt from the Coniractor's � j Litensc Law iur li�e fullowing reason(Seciion 7J31.5,6Usi- � CitV - Tal.Na. � ness and Professions Cnde): " , � � 1,as owner of Ihe Oroperty,am ezdusively contracting _ - � wilh licensed contrectors to construc� the project . ' (Section 7044,Business and Profe�sions Code). : ' . . CONSTRUCTION LENDING AGENCY � . I hereby affirm that there is a construttion Iending egency ` , for the performance of the work for which this permit is . issued(Sec.3097,Civ.C.). ' �� , :r l�.���.:i'� , Lender's Name � \ , � < < < �5 , Lender's Address � 1 certify that 1 have resd this�OP�ication and state that the I ��'� �,��%i above informetion is correct.I agree to comply with all County SEE REVER5F.FOR EXPLANATORY LANGUAGE ' � :�'{;(;' ordinances and State laws re¢ulating Plumbing, and hereby ' • " � aufhorize roDresentative of this County to enter upon the '. � - • � ab - entioned prope to 'nspection purposes. • � � � � • ����'� �' ���' ' ��.��ol�a: Signature of Permittee Date � < '� CI� � 2 � � 9 C �Dp Z �+y C1O N N O 7 yC.� . D ?f C O mv, r ��-� a � .� z c� � D , . .. _ - _. . .;a. � 2.�I N Z I� r^ �y 2 7l � � � �� 'Ty' vw�' % � � � � 1 2 i�•� O . - � �� i T`I 7 � � '' ^ • O I p I�+'^ y �• p L . . '�± ��T� � T Tw� , � O � ..- r': I (� o �,�'x ' � � , N . . ' , ' , -I, i:t� :�" '� . � ' , ' - . ti:'' N ,�N I`I � � ` �. O . .. , - j � •� p�� o ; . . .. ,.� , �'� ..�.' � ��y _ . � • � � - L � m . 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