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Home My WebLink About1226A WORKERS'COMPENSA71ON DECLARATION qpp�ICATION F4R PLUMBING PERMIT �� I here6y offirm that I have a certificate of cansenl lo self lyq�67q , msure,or p certifimle of Workers'Compensation Insurance, CE SV(R[V.10/81) ��„ or a certified copy thereof(Sec.380Q Lab.C.) COUNTY OF LOS ANG`�LES� BUILDING AND SAFETV Po,;�Y�8632138gom�,�emont Indemnity . �/'�-d��t 530/D J � , � Certified copy is hereby fumished. � FORAPPLIC4NTTOFILLM�PRINTORTVPE) BUILLIING -(pr/ T(I�1�OS Certified mpy is fJed with the county building inspeo ADORE55 7ion department. (� NUMBER fIXTURE OR ITEM @ FEE ��ALITY 8/14/8 6 RCR B : a�(t `NF�7ER CLOSET / Oate Appli4o^t "cRossss, ° en 5prings/Carpio CERTIFICATE OF EXEMPTIQN FROM WORKERS' �, BATH TUB COMPENSATION WSURANCE � OWNER � (Thlt s�ction nwd nof b�completed tf th�work Involved by � SHOwER 1h�p�rmif I�for on�huodnd doilon(5100)or Ins.} lqVAiORV � — Ma�� 1�]4 Parkview Dr. ADDRE55 I cer�ify thot in the performonce of the work for which this SINK � „ CITV Covina TE�.Q�7-9541 permit it issued,1 shall no1 employ any person in any manner so os to become subjact to the Workers'Compensalion lows, p15HWASHER � � ' ' ' � ' CONiRACTOR f"+e Applicant � CLOTNESWASHER -- A��RESS12]H.S Md nolia �ICE TO APPLICANT: If, affer making this Certificate of SWIMMINGPOO�RECEPTOR g txempiion, yoa shoold become subjec� to the Workers' �� ivers�. B �� N — � Compensation provisions of the Labor Code,you must forth- LAWN SPRINKLER SVSTEM with comply wi�h such provisions or this parmil shall 6e STATE 3642 LIC.C— deemed revoked. � WATER HEATER UCENSE NO. CLA55 � IICENSED CONTRACTORS DECLARATION �ISiRICT NO. PROCESSED BV I hereby offirm that I am licensed under provisions of Chapter 9 GAS SVSTEM OUTLEtS P . �l,� (commancing with Saction 7000)of Division 3 of the Business OUTLETSOVER L�� I and Pro4essions Code,and my license is in fall force ond effect 5 KR SYSTEM FINAL ` �ATE �/g 1�.7 AIIDATION 0. license Number 33b428 �ic.Class C-36 �� RCR Pluinbing 8/14/86 eiYA� v Contrador Da�e � ! � OO I om exempt under Sec. v B.BP.G.for this reason W Plan check fee .9 1 2 2 6 A va'i Dare: p�UM81NG PERMIT ISSUING FEE S �� Z Signot�re a • s � TOTAL FEE ��('� �`6 •5 Plan check applicant . � '� e�8�5 Q �.-.. SINGLE FAMIIY ' HOME OWNER-BUILDER DECLARATIQN Name ° �� '� �:��Q� �..araby affirm thai I om exempt from ihe CoMrotror's License Address Law for ihe following reason(Seclion 7031.5,Business ond rl£`�,Jr"8 6 Professions Code)a G�ty Tel.No. ❑ I,os owner of the property,will do ihe work and ihe � structure is not intendad or offered for sale(Section 7044,8usiness and Professions CodeJ. � CONSTRUCTION LENDING AGENCY I hereby affirm iho�there is a<onstrudion lending agency for the performonce of the work for which rhis permit is issued (5ec.3Q4F,Civ.C.). L€nd€r's FYar�ie LendEr's A7hfl'eis 1 cenify thot I hove read Ihis applicolion and s�a�e lhat Ihe ► above informotion is co�rect.I agree ro comply with o�l Co�nty ordinances and Srale laws regulating Plumbing,and hereby ootho�ize repre�entallves of this County 10 enter �pon 1he a6ove-ment ned propeny orinspeUion purposes. � �� SEE REVERSE FOR EXPLANATORY LANGUAGE RCR By_L;fahxQ�ni � >R�1 4�g(1- Signature of Permittee Date � � � � �� ,...:,.,.� , , � ,�.� f L...»�, .�. • �,.,�.. ACFROVALS DATE INSPECiOR'SSI�NATURE �NSPECTOR'SNOTE$ OWNER-BUILDC-RL��CI.4RAIiON UNDER SLA6 WOkK �v � � I here6y affirm�h�!I a .xerTlPt from�he Canircclor's ROUGH PLUMBING �� - '— License Law for the following r n (Sec�ion 7031.i. GAS CiPING � �^(� ' - 8usiness ond Professions Codei:Any city or rouniy w;i�ch GAS VEN7 � requires a permil}o cons}rucf,ol/er,improve,demolish. HOi WqTER HE4TER � or sepaic.any sfructure,priar�o ifa �ssuonce, a7so re� - quireaTheoppli[ontiorsuchpermiffofifevsignedstnle- P;UMBING FI%TURES � � menl tha�he is licensed pursvan,•la fhc provrsicns of the GAS7EST /p g`"�' (. Controcto�'s Llcense Law(Chap�er 9(commencrng��i;h UTILITY CO.NO?IFlED _ Sectlon 7000)01 Division 3 p!�ho 9usiness ond Profes- . sions CodeJ w thaf he is exempf tharelrom ond�he basis ' for the aflaged exempilon. Any violo�ion oi Seciion FinlA� �n(er on �ronE � � � 7031.5 by ony applicont for o permit subjecls Ihe appli- � taM to a tivif penafty of not mwa Iban live hundred do7lors($S00).: iN�USTRIAL �� , . ❑I,os owner of fhe properiy will da the wori—,nd WASTE AFP20VAl -- iMe SffUCtUfe is not iMended or offered for sale. �� (Sec.70M,Buslness ondProfess(oea Code: TMConrroc� . _ . � ior's Lleense Low doas rret apply ta on owner of pvop.r�y - � � � . w6o builds or lmproves fherxon, ❑nd who does such � wo�k himseff provided ihol such improvements ora not fntended or olfered for sofe.If,howevar,ihe building or � , �. - improvemenf Is sold wFthin one yeor a(compietion,fhe . ownervbuffder wrfl have tFe burdon o!proving tho!be did � not build or improve for�he purpose of sale.)- � I am exemp!under Sec. B&P.C.for ihis reason � Date Owner iNSPE�T�R'S1+1QFE5