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Home My WebLink About1223A z �- � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT {� 1 here6y affirm that I have a certifimle�of conseM to self 76A667A insure,or a certificate of Worken'Compensalion Insuronce, CE 817(REV.10i81) �� or a ce�rfied mp ihereof(Sec 3800,La6.C.) COUN7Y OF LOS ANGELES BUILDING AND SAFETY a�Y�863�1384�omPo remont Indemnity �3 2� Certified copy is hereby fomished. � �```"� ^ fOR APPLICANT i0 FILL IN(PRINT pR TYPE) BUILD NG � `% J I Certified copy is filed with the county bu'ding inspec- ADDRESS .� AI'Llllt.05 2L tiondeporimenf. j NUMBER FIXTUREORITEM (� FEE Diamon Bclr 8/14/8 6 RCR B wnree aoseT �ocnurv Da�e Applicont y'� � �� — NEARE57 CERTIFICATEOFEXEMVTIONFROMWORKERS� �, BATN7UB /� � CROSSST. OI.CI 11 S r'n s Car 'o COMPENSATION INSURANCE SHOWER OWNER The. Anden Group (This s�ction ne�d not bo compMt�d if tho work involvad 6y �he �rmir is!or on�hundred dollon SI00 or I�as. � MAa - P � ) } p"Z, IAVATORY �4 — ADDRE55 I certify ihpt in the performance of ihe work for which this � permit is issued,�sholl nof employ ony person in any monner SINK CITY Covina - TE��'�57-9541 so as to become s�bject lo the Workers'Compensalion Laws. D�SHWASHER � --� CONTRACiOR R.C.R. P1umb ing� In(.'. �e opplicant CLOIHES WASHER — qDDRE55 fICE TO APPLICANT: If, after making ihis Certificale af SWIMMINGPOOLRECEPTOR � rxemption, you should become sobjed ro the wo�ke�5- c�Tgiverside 92503 � TE�.Nd.371-5000 Compensofion provisions of iha tabor Code,you musl forth- �AWNSPRINKLERSVS7EM ith comply ith such provisions or ihis permil 5hall be STATE LIC. — deemed revoked. WATER HEATER �ICENSE NO. CLA55 - LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCE55ED BV I hereby affirm��hot I om licensed under provisions of Chop�er 9 GAS SYSTEM OUTLETS O (commencing with Sectian 7000)of Division 3 of Ihe Business OU7tETS OVER and Professions Code,ond my license is in full force a�d effect. 5 PER SY57EM DA EL � y �¢7 V IDATION y; Ucense Nom6er�'�b4�R Lic Class�'-�� RCR Plumbing 8/14/86 F'""� � Gontraclor Date BY I ❑ � I om exempi�nder Sec � W B.&P.C.for this reason Plan check fee ► d. Date: Q y PLUMBING PERMIT ISSUING FEE$ � Signature . TOTAL FEE � J� �`.�� 2 2.J A �Plan check applican� Ft o a • m •,5 r..�.. SIN6LE FAMILY HOME OWNER-BUILDER DECLARATION Name � � �7��O �..ereby o$irm tha�I am exempt from Ihe Coniroctor's license Addrass Law for the following reoson(Section 703L5, Business and �, ��J�� Profassions CodeJ: Ciry Tel.No. ❑ I,as owner of iha property,will do�he work ond fhe �E'�C J�—Pi 6 siructure is not intended or offered fo�sale(5ection � 7044,8usiness and Professions Code). CONSTRUCTION 1EN01NG AGENCY 1 heraby nffirm thof�here is o constructian lending ogency for the performonte of fhe work for which Ihis permit is issued ��Sec.309I,Civ.C.). � L-emYbYr Fttrme kernier'r Rdtlress � I certify ihat I hove read this applicotion and sta�e ihat 1he � above informo�ion is correcr.I ogree to comply wiih all Counly ordinonces ond State laws regulating Plumbing,and here6y au�horize representotives of this Co��7y fo enle� upon Ihe above-me 'oned properfy r inspection purposes. SEE REVERSE FOR EXPLANATpRY LANGUAGE 8/11�J8b Signoture of Permittee Date �'�� .,. ... ..+��r��.�. �r.��. �1l� �'_. .""► "�"��`��"_�� APPkOVALS OATE INSe�CTOR'SSIGNATURE INSPECTOR'SNOTES O4VIUER$UILDERDFCIARAiION UNDER SlAB WORK �' . �. hereby nFfirm fhol I om er.empf from Ihe Centrccre�'a ROUGHPLU/deING a�.{�, ��{ License Lav+ for ?he £o�lowing renson (Sec�ion 703I.5. GAS PiPING j . Business and Professla�s Cede;:Any ci}y or<ounty wh�ch GAS VEN7 . requ'rras a permit fo consfruci.ofter,improve,d?moli5n. � �or repair any sfrudure, prior to ifs Issuonce, nlso re- HOT WATER HEATER � - - qulres the applicant lor such permi�to(ile a signed state� PIUMB:NG FIXiURES � ' ' � ment(hot he Is 1lcensed pursuanf fa the provisicns of 7he GAS TEST J Contracfor"s License Law(Chpplor 9(commencrng�•�iih UTILI7YC0.NO7IFIE� Section 7000J of Division 3 0l fhe 6usiness and Profes- sfons Code)ar thaf he is exempt therefrom and�he basis rc7 /or the alleged exempfion. Any viololion oi Secfion FIKAt G fvr an J�ronE ' - 7031.5 by ony applitont 1or o permil subjecis Yhe oppli- . , cant to a c'rvif penal}y of not mare lhon(ive hundred . . ' .. dollars(8500).: INDUSTRI0.t � �� . ❑I,as owner cf the properiy will do�ho wor%—�-nd WASTE APPROVAL � � � — � fhe sfruclure is not intended or offered for scle. � - � � (Sec.7044,Businoss and Proiess�ons Code: 7he Contrar � � for's Lleense Low does ttof apply ro an owner of proper�y � � � - � wBo budds or improvas thereon, and who does such � � work hlmaeff prov�dod�bo�such(mprovemenfs ore no� - Jnfended or offered(or sale.If,however,fhe 6uilding or ' . - Improvement Is sald within one yeor of campletion, fhe . ownsrvbutlder will have fhe burdan ol proving thol fie did . nof build or tmprove for the purpose of sale.J I am exemp!under Sec. , B&P.C.for ihis repson . � Date Owner IIJSPEGTOR'S NOTES