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Home My WebLink About1222A WORKERS'COMPENSATION DECLARATION ppPLICATION FOR PLUMBING PERMIT I hereby offirm ihtlf I have a ce�lifimfe�of consent io self �yq��q � '�'./ Fnaure,or a cerlificote of Workers'Compensation Insurance, CE BV(REV.IOi81) ._..>...._ ar o cerfified copy thereof(Sec.38D0,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY�� O�Y r,JgTP8632I3�mPo�remont Indemnity ;�b Certified copy is hereby furnished. � FORAPPLICANTTOFILLIN(PRINTORTYPEJ BUIl01NG � C�� AT,m1tOs Cenified copy is tiled with ihe county buiiding inspeo A�DRESS '�" lion deparlment NUMBER FIKTURE OR ITEM C FEE �OCALITY lamon ar �1e 8/14/86 APP�itant RCR B : ,3 WATERCLOSET � — CERTIFICATE OF EXEMPTION FROM WORKERS' BA7H iUB �� --_ c"eosssr.Golden S rin s Car io COMPENSATION INSURANCE SHOWEz OWNER The� Anden Group (This a�ctbn na�d mf 6�romplet�d ti Iha work inrolvad by MAIL fhe pormif is for on�hundr�d dollors(5700}or lesi.� LAVAiORV f A�DRE55 � I certify that in the performance of the work for which this permit is issued,I sholl no�employ ony pe�son in any monner SINN � .�- CITY Covina �E��"9�67-9541 � so as to become subjec�to�he Workers'Compensa�ion Laws. ot5Hwa5HEk CONTRACTOR R.C.R.- P umb ing, Tnc. ,/�'��4 Appliconf � CLOTHES WASHER �- ADDRE55 � ;ICE TO APPLIUNT: If, ofler making �his Certiticate of Exemption, you shoulCl bemme subjecl to the Wo�ker5 SWIMMING POOC RECEPTOR � . Compensalion provisions of the Labor Code,you must forlh- �qWNSPRINKLER SYSTEM �'T''Riverside 92503 TE�.No371-5000 with comply with such provisions or this permil sholl be STATE LIC. - d9emed revoked. WATER HEAiER LICENSf NO. CLA55 � IICENSED CONTRACTORS DECLARATION oiSrRicr NO. reoCe55Eo sv � I hereby affirm ihof I om licensed under provisions of Chap�er 9 GAS SVSTEM OUTLETS �q r Q �a� (commencing with Section 7000)of Division 3 of the Business OUTLEf50vER J I and Professions Code,and my license is in full force and effect. 5 PER SVSTEM FiNa� ��-7 VALIDATiON � � ��/ License Num6er 3._3b428 �ia Class C-�F+ DATE O RCR Plumbing 8/14/86 BYAI V CoNrador Da�e � I � O I om exempr under Sec. � 8.8P.C.for this reason � a Plan check fee �� PLUMBING PERMIT ISSUING FEE$ � � Signature TOTAL FEE � . 1222A Plon check opplicont _�^- SINGLE FAMILV �;m o e .e 5 ' HOME OWNER-BUILDER DEC�ARATION Nome � i��ere6y affirm thar I am ezempt from the Contractor's License Address � ` ��Q 5� Law for ihe following reason (Section 7031.5, 6usiness and Professions Code): City Tel.No. • e +��. ��-� ❑ I,ps owner of the property,wi�l do the work ond the � �� C 5,�8 6 siroclure is nof inlended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby nffirm that fhere is a mnsirucfio��ending agenq for the parformance of the work for which this permit is issued (5ec.3047,Civ.C.). Lender's Rlame LendBr's Rdtl(sis. . . . I cenify thot I have read this applimtion and state Ihat�he ► o6ove informotion is correcr.I agree to comply with all County - ordinances and S�o�e laws regulating PIum6ing,and hereby o�thorize representatives of �his County ta enter upon the above-menti �ed properry for inspection purposes. SEE RBYERSE FOR EXPLANATORY LANGUAGE R/14/Rfi Signafure of Perminee ��1e ! 1� � �� -• . +�r�r..s...+..�.a �w.� •1 � � �iM�i i�� • � ��^�� ' — . APPROVALS DATE INSVECTOR'$SIGNATURE INSPECTOR'SNOTES � OWNER-BUILD[RDECI..4RAlION LINDERSLA6WORK � � �� I hereby affirm fhaf I am e mpt from the Cenirecter'_ ROUGH PWMBING 0 l/ t'.1( L k'j�. License Law for the follow'n.g r n (Sec+ion 'G31 5, GAS FiFMG ,1/�� __ 8usiness or,d Professions Code!:Any elfy or co��nfy wb�ch GAS VENi � - . �eqV�res o permi�fo construcf,alter,impro�e,demol�sh. � � or�repair any strudure, prior ro ifs issuance, also re- HOi WATER HEATER � ' � �quiras the applicant ior such permit fo fife v signed stnle- PLUMBING FIXTURES � - � � men!thof he is licensed pursuant lo Ihe provisions of the GAS TEST � � Contracfor's Licanse Law(Chap�nr 9(commenc+nq wi'h UTIIITv C0.NOTIFIED Sectlon 7000J o(Dlvisian 3 oi tha Businsss ond Profes- sions Code)o�tfiat he is axernpt therefrom and Ih=basis � � � for fhe o/leged exc�mpllon. Any violvlion of SecHon FINAt � Ln(�.r on �ronf 7031.5 by any apphmnt for a permif su6jects the appli- cant�o a crvif penafty of noi more�han Iive hundred . . .. . . . dollars($500).: INOUS7RiAt � ❑I,as owner of ihe property will do 1he wor'—nd wqsie qPveOvn� � the s�ructure is not intended or nffered for sale. ; � � � � (Sea TOM,Buafness ond Pro(essions Code: 7he Connoc- - - . � � . �� for's Litense Law abes nof opply eo an owner ol properfy - � � �� - - who builds or lmproves ihereon, and who does such .� work himself provlded tha�such improvoments are nol , intended or offered for sale.lf,however,/Fre building or � _ . Improvement is sold wifhln one year o1 comp;etion, rhe , owner6uildar will have�he burdcn of prowng�hat he did � , nol 6oifd or Improve for fhe purpose of sole.J 1 am exemp`under Sec. , B 8 P.C.for This reason Dofe Owner IIVSPECTOR'S NOTES