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HomeMy WebLinkAbout1180 SO DIAMOND BAR BLVD (2) ' WORKHRS'COMPENSATION DECLARAT[ON '�awss�w � '� I•hereby affirm that � �,n�e��certificate �f��n5�t to st�f �: �E�a,�,=-sa, �APP.L.ICAT:ION�FOR��;PLU�.MB�;I��NG.�P�ERM, '�IT insure or u certificate of Workers'Compensation Insurance,or � � � �'' �� 3?�s 7 A , � .a certiFied copy thereof Sec.3800,Lab.C.z . : ' . WG�pt�y37�� pfbAN48 CewktiY ' COUNTYOFLOSANGELES c BUIL�tNGANDSAFETY �':PolicvNo. Companv �`/1/' .:�� .. . . � c�� il� 0 "" GN P�E2M'\�IT . ,'.��' �� Certified copy is hereby furnished. • i� FOR APPLICANT TO FILL IN(PRINT OR TVPE) qDIDRESS ' i p� S v, D!a i�...e r�d 8 pjvl:�: �-.�.� Certified copy is filed with tlie county building inspection � * NUMBER PIXTURE OR ITEM � FEE Z L�� LOCALITY D�0.�NOHd sar ' `�P r.�/t!n��; � WATEFi CLOSET NEAREST �Dake�tMf;_�—Applicant�44A Q!�$ MF.C'�• �: . . BATH TUB C(7055 ST. G r d k� '�CP:RTIFICATE OF.LXEMPTiON FI20M WORKERS' � COMPN:NSA7'[ON INSURANCE � SHOWER - OWNER �,�G � S� � ��S . CO+ LAVATORV 1'✓� /1� MAI� � :� (Tfiis section need noY�be completed if t6e wock involved 2 � ADDRESS : y --��by the peimi[ is Por one hundied dotlars ($100)or teas.) t � SINK �-' �k� � . i� CITY TEL.NO. �,^J �: U �� I certify Ihat in the performunce.of[he work foc�vhich this � DISHWASHER A Q(l,H �'p�s M G G H � CONTRACTOR �permit is ixsued,[shail not employ any person in nny manner i __ G �� so as to become suNJect to the Workers'Compensaiion Laws. �, CLOTHES WASHEH qDORE55 � � Date Appiicant + 3�2 wd�hw� A VG a . SWIMMING POO�RECEPTOR �,�:. NOTTCE TO APYL[CANT:�If,-after making this Certificute of � � . .CITYQ wG(�a, P4 y�, TEL.NO.sj,�—qM � - ,- lxemptwn, you Fhould become subject tu the Workers' LAWN SPRINKLER SYSTEM � STATE f .UC. y � ��. Compensation provisiuns of the Labor Coda,You must forth- �/ " LICENSE NO.�So O�� CIASS ,7 y'��'yt � I �with comply with such provisinns or this permi[ shall be f�� WATER HEATER ...�.. �7 L° {�� deelned revoked. DISTRICT NO. PROCE35ED BY � ; GAS SYSTEM OUTLETS � LICRNSEDCONTIiACTOitSDF.CLARAT[ON :-,y� OUTLETS�OVER � JL�? r �� �.t.e�.,-L.i° � -- I hereby affirm tLxt 1 am licensed under pmvisions of Chap[er -.; 5 PER SYSTEM � 9 (commencing with Section 7000)of Divuion 3 of[he Busi- I� L G. 1 F�N'4L p � VALIDATION .�-ness and Professions Code,and my license is in full force and� ia ' �t'�h k� r04.1.,41 ��-' DATE �/� O� � � `/ FINAL __ /— �7 'efC�ct. � ��.License Number�s6o 3� Lic.Ctass 3��3b r7 Z y� Bv ��'��� / � I ContructorAQ�A FlPtr Dxte ° ':� 1 am exempt from-the liceAsing requirementx as 1 dm a ,� Plan check fee � 1iCensed acchitect o[ e rogistered professional engineer �;� pLUM6iNG PERMIT ISSUING FEE$ � i� � acting in my profexsionai capacity (Section 7051, Bus- 's iness and}'rofessions Code). � � �� TOTAL PEE .� ;7 *;;�[� �� � ����,aa ��i,ic.or Re'�.No. llate :,� Plan check applicant - . ���%f #{.6.T O 0 0� �: HOML'OWNF:R BUILDER DECLARAT[ON � Name � ; I � a40,50 .�x: . « e.., ,h ��r, r t�r'.e : Address ' . _ ._.__ . � �L�cense�Law`�for the fullowing Vreasnn(Sechon 7031 5 Rusi- j City Tel.No. ' ' � °4 ,�G�� � �_ neac and Prufessiona Code): � a�� � � � �� I,as o�vner of the property,am exc]usiveiy cuntmeting ..Fpj ��5'U 1 �'8� with ]icensed contractors to construct the project � (Section 7044,Business and Yrofessions Code). '����� ' �� CONSTRUCTION LENAING AGENCY �,.�F � I hereby affirm tha[ there is a construction lending agency }�'� � for the perfurmance of the wn[k for which-this permii is . ��issued(Sec.3097,Civ.CJ. � Lender's Name . Lender's Address � 1 certify thnt I have read this applicatiun and state that the � � above information is correct.[agree to compiy with all County SEE REVERSL'POR F.XPLANATORY LANGUAGE � - � ordin:u�ces and Stute luws regulating YWmbing, nnd hereby � authorize representatives of this County to enter upon the - - �a e-mentione ro rty fot inspectio��pu�r�se.s.�� �� 7/� I 1 Signature of Permittec llate . . . . .. . . . .. . . . . � . . . ' ��z � -n � j C C i�:2 �L� GI JJ C � , � ' ,.�,�{GI .i.k �� D ��io � ui;0 z ; I � . � i � �� � W � ��� � �Iy. I � �m� < .Tz:>: �„ -� � � � � � �� 1. 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