HomeMy WebLinkAbout1164A (5) � 'WORKERS'COMPENSAi[ONDECLARATION �eweaw �
I heredy afCam that ! have a'cettiflcate ufconaept ro se�f �e.,,�=..o, APPLICATiON FOR PLUMBING PERMtT
insure, pr a certiPcate of Workers'Compensation Inaurance,or _.
a certifded cop1�thereof(3ec.3800,Lab.C.)
WC1u68426 Mi Iuro Assoc. COUNTYOFLOSANGELES BUILDINGANDSAFETY
.Policy 17Vo. Campany --
� � Certified copy is here6y turnished. FOR APPLtCAN7 TO FI�L IN(PRINT OR TYPE) BUILDING
AD�RESS
� Ca[tified copy is filed with t e o uilding in pection NUMBEF FIX7URE OR ITEM � fEE .
do artMent. � � � LOCALITY Diamond Bar
P �'"��, WATER CLOSET NEARE5T
Date Applicant
BATH TUB CRO55 ST.
CET.RTFFiCA1'E OF EXEMPTION FROM WORKERS' ;
COMPENSATIOMINSURANCE SHOWEq OWNER
MAf L I
(This seCt100 need not 6e cOIDp1¢tCd if tlie wOik IllvOlv¢d LAVATORY ADORESS Same I
by the permit is for one hundred doilazs(SI00)or less) SINK } �
CITV TEL.N _ 4 O p i
I certif_y that in the performance of the work tor which this DISHWASHER
permit is issued,I shall not employ anY person in any manner CONTRACTOR h om a s G r o u p � �
so as[o become su6ject to the Workers'Compensation Laws. CLOTHES WASHER AODpESS � j
Date AppYicant SWIMMING POOL RECEPTOR • U ;
. NOTiCE TO APPWCANT:Ii,after making this Certificate of CITV TEL.N � a �
Exempt[ion, you should become su6jeM to the Workers' LAWN SPRINKLER SYSTEM
Compemeation provisions of the Laber Code,you m�st forth- LICENse r,o. 3 5 5 5 42 C ASS S��h 4 Z
with comply with such provisions or this permit shall be WATEF HEATER j
deemed revoked. GAS SVSTEM OUTLETS D15TRICT NO. PROCESSED BY �
.LICENSE➢CONTRACTORS llECLARATION QU7 LE F5 O V E R �O (!/{.(�
I hereby�aff'vm that[am licensed under provisions of Chapter 5 PER SYSTEM
9 (comrnencing with Section 9000)of Division 3 of the Busi- FINaL VALIDATtON
ness andl Rofessions Code,and mY licertse is in full force and DATE L7 �G �Z
effect. �D
FINAL .
Licenae LYumber�.3. Lle.Ciass�—_ eV L�({�J�i�CAV� S
i
Contract o�h 0012 5 C ro lJ PDate � �
� I am exempt from the licensing requirements ae[am a Plan eheck fee .
lice:nsed architect or e registeced professional engineer p�UMBING PEfiM1T ISSUING FEE$ �Q _
actins in my professional capacity (Sec[ion 7051,Hus- �
iness and Professians Code). _ TOTAL FEE �,� J`� {
�7
Lic.or R�eg.No. �ate Plan check applicant §
3
HOME OWNER-BUILDER UECLARATION Name �
i
/ herebyi affirm [hat [ am exempt from the Contrecfor's /{adress i
License Law for the toUowinB reason (Section 7031.5, Busi- City Tel.Na. �
ness and Professions Code): �
� I,a:a owner of the property, am exclusivety contracting _ �
witlh licensed contractors to construct [he project �� � (a(y A �
(Section 7044,Business and Ptofessions Code).
WNSTRUCTION LENUING A(GENCY #���� ��5 �
J herebyr affum that there is a construction lending agency . � •��Z 5�
for the performance of the work for which this Ovmii is
issued(S�ec.3097,Civ.C.). • ••�1 2 5 p czi
Lender's Name �
LenJer's Addtesx G a 5 �0. �2�0�'8:�
� I certify that I have read this application and state that the �
� abuve inSormation is mrrect.1 agree to comply with all County SEE REYERSE FOR EXPLANATORY-LANGUAGE - � � � � � -�
ordinunces and State taws r¢guiating Plumhing, and hereby
authoriz�e ropres ati�e . t this C unty to enter upon the �
above-m�ntione�ope y r inspe ion puryoses. �
�
Signature of Yermittee te . i
�
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