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Home My WebLink About1224A WORKERS'COMPENSATION DECLARATION APP�ICATION F4R PLUMBfNG PERMIT � I he�eby offirm that I have a certifimte.of consem to self 76A667A insure,or a certificate of Workers'Compensafion Insurance, CE 817(REV.10/Bl) or o cerlified copy thereof(Sec.3600,Lab.C.} COUNTY OF LOS ANGELES BUILDING AND SAFETY � Po,;�Yi�g.8632138�am��emont Indemnity �y,�� ._� �.. � Certified copy is hereby furnished. BUILDI G FORAPPtICANT7pFILLW(PRINTORTYPE) qDDRE55 AIZIII�COS Certified copy is filed with the county bui ing inspet- X fion departmenf. NUMBER FI%TUREOR ITEM � FEE ��, Diamon Bar � Daf�B/14/86 APPlicanfRCR B I WATER CLOSET �o'�- — NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' sAiH tUe '� _ CRO55 Si. ' COMPENSATION WSURANCE SHOWER �OwNEa The� Anden Group (Thit��cfion nud nof b�eomplet�d if 1h�work inrolv�d by fh� �rmit is for on�hundr�d dolbrs 5100 or I��a. } MAa P ( ) ) .Z LAVATORY � -_. ADDRESS I certify that in the performance of the work for which�his ' � permif is issued,I sholl nol employ any person in any manner SiNK CITY TE�. Covina '�l'67-9541 so as fo become subject lo the Workers'Compenspfion Laws. DISHWASHER CONTRACTOR R.C+.R. P umbing� 111C. /'^te opplicaM f CLO7HES WASHER -- ADORE55 � TICE TO APPLICANT; If, ofrer making ihis Certifimte of SwIMMINGPOOIRECEPIOR exemption, yoo shoold become subject fo Ihe Workers' aT�{iverside� 92503 TE�.No371-5000 Compensa��on provisions of the Labor Code,you musf fo/1I1- �qWN SPRINKIER SVSTEM with comply with such provisions or fhis permit sholl be STATE UC. – deemed revoked. J WATER HEATER LICENSE NO. CLA55 LICENSED CONiRACTORS�ECLARATION � ��_ pISTRICi N0. PROCESSED BY I hereby affirm fha�I am licensed under provisions o4 Chapter 9 GAS SYSTE/21 OUTLETS — � (commencing with Sec�ion 7000)of Division 3 of rhe Business OUitE1SOVER ', and Professions Code,and my�icense is in foll force and effect. 5 PER SY57E�w FINAL G VALIDATION . DATE 2 5/D 7 �, License Number3,3b./{.2$ Lia Class (y–�.(j � RCR Plumbing 8/14/86 FINAI � ConlraUor Date BY � I � O I am exempt unde�Sea U B.&P.C.for this reason W Plan check fee a Date: pLUMB�NG PERMIT ISSUING FEE S ) Z Signoture –� 70TAL FEE � �•� 2 G U A Plan check applicam 7i e c� c s rj f,.–.. SINGLE FAMILY HOME OWNER-BUIIDER DECIARATION Name � o �7�tJ Q �..ereby affirm ihdt I am exempt from the Coniracror's License Address Law for ihe following�reoson($ecfio�7031.5,Business and ". " ,� /(;,J C� Professions Code): City Tel.No. ❑ I,as owner of fhe property,will do the work and the �F�`5��b structure is not iMended or offered far sale ($ection ► ` 7044,Business and Professians Code). CONSTRUCTION LENDING AGENCY I hareby affirm thot ihere is a construction lending agency for tha performance of the work for which this permit is issued � ' (6ec.�47,Cir.C.�. Lenefer's F9tme ker+db�'e Artdrase 1 certify rhof I have read Ihis applimtion and s�ate thoi the ► above informorion is<orreU.I agree to wmply with oll County - - ordinonces and$tate laws regulating Plumbing,ond here6y - a��horize represenra�ives of this County to emer upon the above-menti ed properfy far inspecflan purposes. � SEE REVERSE FOR EXPLANATORY IANGUAGE • � e. R�14/Rh Signoture of Permiitee Date `' �4�1��'�/�i �.� .•- •�- �*�*- �� ,�,. ,� - - � APPROVALS� � � DATE INSPECTOR'SSIGNAiURE INSPECTOR'SNOTES OWNER-BUIIDERDFCL.4RAlION � UN�ER SLAB WORK ^t7 � I hereby offirm thaf I am er.empl from tne Confrec�c%; ROUGHPLUMBING License �aw for ihe followirq recson (Secfion 703L5, GAS PIPING ,fii'� � FSusiness and Prolessions Codej:Any city or ro��nty wFi�ch GAS VENT requlres o permif to construc�.aNer,improve,demolis,4. or.repoir any s}rutture, prior lo ifs lssuonce, also re- HOi WATER HEATER � � quires the�appb[dnt for such permif fo file o signed s7afe- PLUM6ING FIXTURES ' � ' ment fhal he Is llcensed pu�suanf}a}he provisions o/fhe GASTEST � 9 �t � � Confroctor"s Cicansa 4aw(Chnp�er 9(commr.ncing�.�i'h UTILITV CO.NOTIFlEp ' Section 7000)of Division 3 of}he Business and Profes- sions Code)or�haf Me is exempf Iherefrom ortd tha bosis � !or ihe o0eged exemptlon. Any vio�ofion oi Sadion fIN.4l � �nter orc �ronl � � , 7031.5 by any applicaN for a permi�subjecfs Ihe appli- cant fo a civif penafty of not more Ihan five hondred � � . �dollars(5500).: INDUSTRIAL - � ❑I,as owner of the property will do the worksnd WASTE A7aROVAL � � � tha ahutfwe is nol iMended or offered for sale. . (Sec.7044.Busfness and Professions Code: The Cw��mc- � � � Tor�Ucsnse Law does rrot apply*o on owns(of property �� wlw builds or improves fhereon, and wlw does sucb work himeeff provided thot such improvemenrs are nof � in}andedorofferedforsu(e.ff,however,TRebuildingor ' , Improvemenl]s sold wiihin one year of comple�ion,fhe � _ owner-builder wilf have f6e burden of proving�hot he did _ nat 6vild or tmprove lor the purpose of sale.) � I am exerr�!under Sec. , B 8 P.C.for ihis reason �ate Owner INSPECTOR'S NOTES