HomeMy WebLinkAbout1750A WORKERS'COMPENSATION DECLARATION APPIICATIQN FQR PLUMBIIVG I�ERMIT
1 hereby offirm that I have a cartifimfe of consent�o self �yp667q ��� �
insure,or a cc lifimte of Workers'Compensafion InsuranCe, CE 817�REV.10/81)
or a cerrified copy ihereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGElES B LDING AMD 5 PETY
Polic���.$.sCompanyFramnnt Tnrlamnj,ty � �,�,,,��,1��/ ��-
Cartified copy i5 herehy furnished. � ' - -
FOR A7PLICANT TO FILL IN�PRINT OR TVPE) BUIIDItJG �
��� � Ceriified copy is filed wifh fhe couMy 6vil ing insp o A�DRESS
tion deparlment. NUM9ER FIXTURE OR ITEM Cw FEE ��p,�ITY Diamond Bar
oo�e bI19/85 APp���a��RCR b : � WATERClOSET V NEAREST
CERTIFICATEOFEX€MPTIONFROMWORKERS' BaTHiUe v. cRosssT.� 60/Philli s Ranch
COMPENSATION INSURANCE SHON'ER OWNER South Countr CQT
(Thic s�ction n��d not br comphS�d if Ih�work(nvoly�d by MAi� � �
th�parmif is fer one hu�dnd dollars(5100}or lets.) LnvnTORv aDDRE55
I certify that in the performance of�he work for which this �
permit is issued,1 sholl noi employ any person in any manner J SINK r QTY TEL N
so as to become subject ro fhe Warkers'Campensation Laws. DISHWASHER
,,.._
/ CONTRACTORR.C.:R. Plumbin INc.
. � 8 Applimnt CLOTHESWASHER ADDRE55
NUTICE TO APPLICANT: If, after making this Cerrifitate of 12]�,�J �`'�3 T1.0�.� V
Exemplion, you shouid become subject lo the Workers' SWIMMINGPOOIREGEPTOR � � �
CITV TEL.NO.
'� Compensafion provision5 04 Ihe Labor COde,y0u must forth- �qWN SPRINKLER SYSTEM R'�V r �
with comply with such provisions or fhis permil shall be S7ATE � LIC.
. deemed revoked. � R'ATER HEATER � ,� ���EN�No. 336428 ��qg� C-36
LICENSED CONTRACTORS DECIARATION P PISiRICT y0. PROCESSE�BY
� GAS SYSTEM OU1lE1S
I here6y affirm ihat I am licensed under provisions of Chapter 9 � �
(commencing wi�h Seclion 70043)of Oivision 3 of the Business OUTLFTSOVER C,
and Professions Code,and my license is in full force ond effecL 5 PER SYSTEM FINAL �//��,� ATION � '
DATE I�/E r"J'S� U
License tdumber 33,6�+25 tia Class C—�Ei— �� _�,, �=
co���ono,RCR P Zt31ttU lrig Date6/19/85 eY"� ��i�".�."9 °
❑ a��
I am exempt under Sec ��rJ
- B.&P.C.for this reason plan check fee � �
.. Date: � �..-�
' PLUMBWG PERMIT ISSUING FEE$
Si noiure
9 TOTAL FEE � r� rI.rA O A
' , Plon check applicant �• • � •!5
� SINGLE FAMIIY
' HOME OWNER-BUILDER DECLARATION Name � � ' . ( • •8 Q,�j O
I hereby affirm thai I am exempi from the Contractor's License Address � �
Low for the following�eoson(Settian 7031.5, Business and • • •8 8 5 U�
� Professions Code): City Tel.N
� - oZ29�'85
I,as owner of the property,will do the work and the
' struct�re is noi intended or affered for sale (Sedion �
, 704d,6usiness and Professions Code�.
CONSTRUCTION IENDING AGENCY
- I heraby affirm ihat rbere is a consirudion lending agency for
� the performpnce of ihe work for which this permit is issued
' (",mc.�T2T,Civ.C.).
. t6�6T'S IOCiTB .
� Lend2q'S fSdMess �
I certify thot I have read ihis opplimtion and stale Ihdi the ►
�, above informotion is mrrect.I agree to comply with all County .
� ordinanws and State lows reg�laling Plumbing,and hereby
authorize representaiives of this Caunty to enter upon the .
���. above-mantioned pr ty for inspe tion purposes. �
� SEE REYERSE F�R EXPIANAT4RY LA7�IGUACsE
x.c.x. ay r.�.�c���r��i 9�R5
�� Signofure of Parmitfee Dafe
"""`�'"' INSPECTOR'S WOTES OWNER-BUfLDER DECLARATION
� APPROVAlS DAiE INSPNCTOR'S SIGNhTURE
UNDER SiA9 WORK `�� I here6y affirm that I am ezempY from-rhe Conrraaor's
ROUGHiN.UMBIMG Q!� ;.�f License Law for Ihe following reason (Section 7031.5,
,GRS PIPtNG Business ond Professions CodeJ:Any cify or coun�y which
-- -- requires a permi�fo consirucq aher,Improve,demolish,
Gk5 VENT +°'
� orrepalr ony sfrotture, prior to Its Iscuonce, also rr
HOT wnie2-HEnilR qvires the applicont for such parmi�to/ile a slgFled stcrie-
PtUMBMiG FI%7URES �- ment Ihai he is licensed porsuant lo the provislons o1 the
Gp,S TlfiT � � •R CoMrocior's License 1ow(Chapter 9(mmmencing with
UTILIN�O.NOTIFIED Sec4ion 7060)of D(visi�+3 07 tho Buslns�ss ond Pro�os-
sfons Cods)or that he is exsmpr therelrom ond the bosrs
�c-j � ' � (or 1he al(eged exemp,`ion. Any violafion af Section
FINAL � � �Er�on r3ront 7d31.5 by any applitant!or a permit subjecls the cppll-
cont fo a civil penalty ol nof more thort five hundred
� doflars(5500J.: —
�iNOU57�s� � � ❑1,as owner of the properry wili do the woi ;d
WASTE Afr�ROVA: fhe struct�re is not inlended or offored for sale.
(Sec.7�4i,BuzfrtessundProfesuonsGocle: iheCoetroc
.. . . io�'s Llaav�r�Low doss not epply to on own�r of prop�nY
� � who buitds or Impeores theFeon. and whv dvas wch
� work himsalf providad thaf suFh impsowments ore not
intended or offeFed for sale.If,howerer,fhe bullding or
improrement Is sald w�lhin on�yrw o!compfstion,�he
owrrerbd�Idep w(N have the burden o{provang that he did
rtot bvlfd or Improve fw ths pwposa o!safe.J
I am exempt under See. ,
B&P.C.for ihis reason
Date
� Owne�
. a ,
, � ,
IN9AECTOR'S NOl'�,9
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