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HomeMy WebLinkAbout1138A . WORKERS'COMPENSATION�ECLARATION �pp��CATION FOR PLUMBING PERMIT �� /� � ' I'hereby,afiirm fha�I have a cer�ifica�e o(consen�ta seif 78AB87A �'I I � insure,or a tertificote of Worken'Compe�wiion Inwrance, CE BV IREV.8/88) � � � � � -� �- i J � �� � � «a cer�ified copy rhersof(See.3800,Lob.C.) � � � - ' - � B a��Q�,937 High]o���s Insurance Co. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS _ Cen�fied copy is hereby furnished. a � FORAPPLIGANTiOFILLIN(PRINTORTYPE) BUILDINC 2Z927 EStL011 DT. Cenified copy is filed wilh the tounty building infpeb ADDRESS NUMBER FIXTUREORITFM � FEE Ama�oie���umbing, Inc. 8/26/87 yyq7ERCLOSET ��m Diamond Bar Dote Appl�sonr 15 6. 90 00 ,,�,,,�T porto Grande/Montefino � CERTIFICAiE Of EXEMPTION FROM WORKERS' � lO eniH 7U8 6. GO OO ��Si. COMPENSATIONINSURANCE� . S��R OWNER Presley Of Southern '� . (Thi���cflon eNd�rof M eompl�f�d iF fh�work Inwlwd br . """'� 17791 Mitchell South th�p�rmlt B for on�huedr�d doilan(5100)or bss.) ZQ L.nVATORY 6. 12 � AppRE55 . I certify t6o1 in the per(ormonca of the work for whlch this . - �permil Is issued,I sFali nol employ ony person in pny monner SINK CITY i=vine, � T��•NO660-0660 " -... so as�o become subject to fhe Workers'Compensalion Lows. Di5HWA5NER 5 6. 30 00 cor,rRncroR �atore Plumbin Inc. . +�re nrpl�canr 5. QOTHfSWASHER 0 00 A��u 127 W. StBte. St. .bTICE TO APPLICANT: If, ofler moking ihia Cerfificate of SWIMMINGPOOLRECEVfOR �-empiion, you should 6ecome su6jecl lo tMe Workers' �iTy n�.ra. 660-066 hPenwtion pravisions of ihe Labw Code,yov mus�foAh- �AWN SPRINKLER SYSiEM Ontario .rfi comply with such provisions or �his pe�mit shall be i,T�"Ns�nw. 355068 cUss C-36 deemed revoked. WATER HEATER � � � UCENSED CONTRACTORS DECLARATION ' Di57cKT NO. vROCE55ED eY ' I hereby offirm thof I om I�cen�ed�nder provisiorx of Chapler 9 rj. �SvSiEM WTLETS (�. 3Q Q Q 1/+� Q (commenNng wi�h SeMio�7000)of Diviaion 3 of tM Business r,� pUitFiSOVFR . . . 1. _7 r,0 �CJ Q. and P�ofessions�ode,ond my Ikense is in full facs and effecl. 5 PER SYStEnn FINAL �j VALIDATION d DA7E�i �O V. ticense Number 355068 �;�,Class C-36 ¢I �Ama�ore Plnmbing, ��c. 8/26/87 BY ° ontro�o. o e V ❑ � W I om eaempt under Sea y . B.BP.C.for this reoson p�a��heck fae � � � Z oo�o: �1138A . • PIUMBING PERMIT ISSUING fEE f ],O SO i;• • • • •S S�gnature n TOTAI FEE 468 �� � . I �d68.b0 ' � Plan thetk appiitant . . . SINGLE fAMILY ' °V��6�Q n�' HOME OWNER•BUILDER DECIARATION Name G�.%3�CS 7 1 hereby affirm rhet I am exempt 6om rhe Cono-anor's License ArJdrwsx - � � � � � � � �ior tne iollowing rea�on j5ection iwi.i,ousiness and euions Code): Ciiy Tel.No. ❑ I,as owner of the properfy,will do the work a�the . strud�re is not in�ended or offered fo�wle(Secrion - - � � - . 7044,B�s�ness ond Professions Code). � CONSTRUCTION LENDING AGENCY � - ��- -� - � � - - � - - � � ��� � I hereby affirm thot there is a conarruc�ion lending ogency for . rhe perfo�mance of rhe work for which this permir is issued � - - - � �� - - - (Sec.3097,Civ.C.). lendcv's Name lande:s Address . 1 certify thot�have read this applicotion and stote thot ihe - - - � ► � - above infamo�ion is cwrect.I ogree 10 tomply wilh all Counry . � o�dinances end S�ate laws regulating Piumbing,ond he�eby _ . . . . . . .. au�hori rc eematives of this Couniy�o emer upon the � abav e o�ed property for inspedion purposes. // p /7 D SEE REVERSE FOR EXPLANATORY LANGUAGE �� �L1_L 8'd . 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