HomeMy WebLinkAbout1180 SO DIAMOND BAR BLVD (3) ' 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
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