HomeMy WebLinkAbout1414A .. . . ..__..._.._._.._ _--.,__^�._- ,,------- _ .
�.__. _,-_._.�
WORKERS'COMPENSAiION DEGARATIOtJ ��pp�,�CATION FOR PLUMBING PERMIT -
1 hereby offirm thot I hore a ca�i�ca�e of corqent to�eff 7 p ��'
� irauro,or a cenificme of Worken'Compensation(nsumnee, qE f7(REµ.�W87) � � '
o.a�enit�ed�cpy rhereot�Sec.360Q,EaG.c.) COUNTY OF LOS ANGELF.�S BUILDING AND SAFETY
I. Policy Na..�,�,�f��pony N e r r F n�A. ,
f Cenffiad copy is heroEry fure�Sshed.-
` � Foa,�wLrc�wr to art�.a��vamrc oR me> �',�pp� fi°3�7 C h d p 8 r a 1
� Cer�Nisd mpy is�i�ed w�+K�he cou itdi�in�peo.
�Yon qpprtmen�. MHER FixTURE at�EM p �E
�nw„r Diamond Bar
ooro qppti5an waiE¢crasEt
� CATE qF FX�k�'!�IQN FRpM' RK S' ��� """�7�'
� ODMPFl�$A�ON'UJSURAN. OWn�ER 5 t e r n s
�� niER
(iM���efbn nMd nef6r po�npt�tad It�Fs�,rerli Inrolwd br
� th�p�rmH��tor on�fiundridVleilott(�iQb�or I�ss.) �e,��� A��
i I cenKy�M�in rhe performonea o#�ha��wor4 for vVhich nc�s
� parmil is iuued,I aholl aotemplo4�Y Cdnan in any monner 51NK CIiY TEI.NO.
� so m lo become au6jecr M Ihe WOeke's 6ompeersalfon Lew�. �����
y CON1�`� - 5unco Jose h R aa tor
�I �ate a'+�+licpnt � GA7MESwAS�ER
i� NOTICE TO APPUCANT: If ane� makimp fhi�tenm�me os Af10f� 2 Q 1 1 Mo�u 1 ten G-1 3�
� Exemprion, yrnr ■honitl becuma mhles��ro Uis�Waken' ���NGR,�LRECEROR .
�� CompensaT�an proxisiont af rhe�ln5or Cede�yuu Tusi fOrIF1- UWN SVRMKLER SnTFM CITV L a U fl d H���S m.�.$59--�G 4
I w'nh compfy wi�h wch ptwuion��or �6is permit sholl be �A� 448833 ��u ��� �
� deemed.evoked WAtEk NEATFR U��.
LICFP15E0 CDNTRAQ�R$OECWRATIQN Dt4TAICT NO. � iRqCESSFD BV
. �harebv affhm eho�Wm lim.�spd-wWe.provisionsaf chapte�v ws srsnrn our�rs /6
:�- (cammenrinp_wi�A SS�CCtlpn 7af0)Ot Qiviafpn 3 of�hp 9usir�ass p��tg OVEp ,
innd Praftssiom Lade,and my htenSp ie infali forceand eked. S 4Ep'6Y51FM �
! q �� 'a� pmest c a e p h,t� � }�� VALI ATIDN �
6 licemoNumbsr��4"���{+e.EiaxsC�4 . � ''-�� "�`�`' V
�
� co�voa« JoseDh RYar�oQ,e 7�17-65 sr�' o
V
W
I� a I om e�amp�unde�Sec. � d
k B.BP.C.tor this reason �
Plon check fee ► Z
I, Oate: �p�uARBInK',pERM1T I$SUING FEE 5 Q
� Signalure �
' �TOTAL GEE .30
jPMn check applmm z'1 4 1.4 Fh
� SMGLE FAMIIV �.. . . . .G
HOME OWNER-BWLLOER DECLARATION Name
� I hnreby aff�rm Ihof I am exempl from Ihe�Gonaocioi s liceine ��� � • •J�l 5� �
� Law for�he 4ollowinp roman(Sectian 7031.5,Buaine�s and o ;
Wofexsions Code): Ciry Tsl.No. �(j"(j�
❑ I,ao ownar o4 tl�e properry,will do rAe work ond�he � o '
I ahuctore is not inferrtled or offered for wle(Sectlon ► ��.7 �'E 5
� 70M,8usinm:nrd Profnaions Cade� -
CONSTftUCTION IENDING AGENCY
�hereby ufHrm Uwt thero b o eonsnanion Yend�nq agenq fw
the Qerformance of�he work tor wfiich thia permit is isaued
� (Sec.3047,Civ.C.� .
� lende:e Nome
� Lende�'s q�drosa . . .
h I eenify+hor I hcre�.ead�his aDFlioprinn and�wie thm rhe � ,
� abo.e iri6amw�ion ie mnen.I ag�Qa to�n Ply wi�h all Caunty . .
ordino�cm ond State lows roguYating Vtumb�n¢ond herebx
�I . autbrnise nfpftrea of this Cyunry to aNer,upon Ihe
aboro- lon.dprOpo�ry ior inspeetion purpmea.
� l� SEE REV�RS�F.�R EXPLANATCiRY IANGUACE-
I• Signoture of P rm e � te , �
„ \
y,.__ � .._
_ -- - ----- __._ ,- --,_ ___ _ .
�
APFROVALS D�.re" iNSPECTOR'SSiGNATURe � INS?ECTOR'S NOTES OWNER-BUILDER DECLARATION .
. UNDE�SUSB W02K �
I heraby affirm 1ha1 I am exempr irom Ihe Con!ractor's
ROUGH PLUMdING - � License Law (or ihe following reason (Seclion 7D31.5,
GAS PIFIN3 • ` � Bvslnesz and Prolesslons Codef:Any cify or covnty which
� GAS VENi �. � requlres o permif fo tonslrod.afler,Improve,demoli�h.
� HOT WATFR HEA7ER � or rspair any afructure, prior lo I�s Issuan[e, also re-
- qulr�s}hs appllmnf for such permJt lo/lle o slgned sfalc-
� FIUMBING FIXTURES m�nt Ihol he Is Ilceneed pvrsuonl fo the provisions of the
' GASTE57 � � . Con}ractor's Ucansa Low(Cbop}er 9(commencing with
� UTILI7Y CO.NO7IPIED , Setflon 7000)of Divlsfan 3 0/the Businaes and Proles�
� s7ona Code)or�hof he is exsmpf f6erefrom ond 1he bcs�.
� n � � /or tfia aqegad exempfion. /Iny violafion ol Secfion
�� Fwat C nle�on �ranf 703L5 by any cpplicont for a pe�mi�sub�eds ihe applb
� cant�o a Nvil penolfy of not morn ihcn five hundred
j ' ' , . dollors(3500J.:
� INDUSTRIA[ - ❑I,as owner of the property will do the work,ond
WAS7E APPROVAL � � �he sl�ucture Is not intended or offered for sd�e.
I � (Sec.79Ml,Buslnoss and Pro/essfons Code� ibe Controa
� " � • � �� � tor i Lk�nse Low doa:oof oppfy to an owner of property
� � . � - wFo bWfds or Improvea thsreon, end who does such
,' ' . ' , work hlmsel(provld�d ihal svch Improvamenfs cre no�
� lnhrtd�d or oNered for sole.I(,howeve�,the buifd�ng or
, . � , Improv�rrrsnl!c sofd wfthln one yeur of compl�flon.!bc
� - � owns�•ba1ldrrwill6avalheburdertofproNng�holhodld
. _ _ ., ; not 6uild or fmprow for ihe purpose of sale.J
I am exempt under Sec. ,
B 8 P.C.for this reason
Dote
Ownar
INSPfCTOR'S NOTES
I
�I
��
�
` .
�