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HomeMy WebLinkAbout1136A (5) }-. �: WORKERS'COMPENSATIONDECLARATION qpp��CATION FOR PLUMBING PERMIT ��///��� ?here6y,offirm ihat 1 hove a cerlificate of consenl 10 self 7gqg87A � � r'�1���sure,or a cerlifico�e of Workeri Compenwtion Insurance, �CE 817(REV.8/88) - " . , . . . _ or o cernfied copy theraof(See.3800,Lab.C.) . � � � � 605739 ands Insurance Co. COUNTY OF LOS ANGELES. DEPT. OF,PUBLIC.WORKS ' PO�"��� ��'� Units 423,424,425 426 527 428 � Ceriified copy is hereby fumiahed. BU4DING � � - FOR APPLKANT TO flll W(PRINT OR TViE) Cerlified topy is(iled wilh the counry building inspec- ADDRESS 22925 Estori NUMBER FIXTUREORITEM � FEE �����, Diamond Bar 8f�`�d1�ml�inatore Plumbing� Inc. WATERCLOSET pa�e nPPi�to�� 18 .1 8 0 ,�r�aesr CERTIPICATE OF EXEMPTION FROM WORKERS' 14 BATHTUB - H4 0� ��ST• Porto Grande/Montefino � . - COMPENSATION INSURANCE S��R OwNER presley Of SO. Ca. - (Thl�rMlon n��d rrof b�compl�t�d if th�work Involwd by 36 �� 1h�p�rmil l�!o�one hundnd dollan�s�oo)o.�«+.) 24 LAVATORY .1 4 0 n"""oo��ss 17791 Mitchell South � I ceriify,thal in the performaoce of the wo�k fw whith lhis - . permil is iuued,I shall not emp�oy ony perfon in pny monner SINK C�TY Irvine . �Te�.rro 660-0660 � �-- so of�o betome subjecl to the Workers'Compensa�ion lows. 6 DiSHWASHER ' � .. 36 00 mrvrrsncroa Amatore Plumbing, Inc. �� �le � epplicanf 6 QOTFIES WASFIER 36 00 � � . -_.+OTICE TO APMICANT: If, ofter moking �his Ceniiicote of ��5"` .127. W. State.St. . F•emp�ion, you sho�ld b«ome subjecl 10 Ihe Workeri SWIMMINGPOOLRECEVTOR �pensoiion provis�ons of the lobor Code,you must forth• - Citv ontario '��•NO�986-5878 � r comply w'�th such provisions or this permit sholl be �AWNSPRINKLERSYSTEM STAh , � �deemed revoked.� � � - WATFR FIfATER IICENSE NO. L�. , LICENSED CONTRACTORS DECLARATION � ' � DISTRIGT Np. GROCE55ED BY I here6y affirm ifwt I om licensed under povisions of Chaprer 9 O GAS SVSTEM OUTLETS 36 00 /'� - (commencing wi�h SeClion 7000J pf DirisiOn 3 of Ihe Business _ 6 pU7tET50VER . �g g O `� �a1� a and Professions Code,and my license iz In fuli force o�d elfect. 5 PER Sv51EM � DAE � � VALIDATION v � ��cense Number 355068 ��c.Class C-36 � o�na oore Plumbing, ��c. 8/26/87 ev� �1-�-- � � � w I am exempl under Set. p, � 6.8P.C.fa this reoson N Plan check fea , �1 1 3 6 A � Dote: PIUMBING PERMIT ISSUING FEE S 10 �j0 r� � � ' 'S s�g�aw�e f •�7 1,5 0 TOTAL FEE S 71 5 O • , Plan check opp(icant . - � ' '�7�.J`J c=i � \ SWGLE FAMILY a,�2 8`8,7 � I� • 1 NOME OWNER-BUIIDER DECIARATION Name . I hereby offirm ihol I om eRampt from the ConMocfor's li[EnsC Addrwss r�t`a`ofloaing reoson jSaUlon:^v31.5, ouainese ond �essions Coda): Ciry Tel.No. ❑ �,as owner of I�e properfy,will do the work and the � structure is not inrendad or oNmed(w wle(Section _ , 7044,Business ond Professions Code). � � CONSTRUCTION LEN�ING AGENCY - � - ��� � � -�- -� � � � � - I bareby oHirm�har there is a consnuction lendirvg oganty for , . the parformance of ihe work for which ihis permi�is issued � - - - � � .�� � (Sec.3097,Civ.C.). � . , lender's Name � - Lender's Addreu . . I roriify�haf I hove read�his epplicotion ond s�ate�hat�he . .. . ► . . , above informotion is correU.1 oqree�o comply with oll County � , ordinonces ond 51ote hws reguloting Plumbing,nnd hereby . � au�hori e re esent 'ves oF fhis County to enler�pon the � � � obov ent ned ro arty for inspection pur oses. 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