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 �
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