HomeMy WebLinkAbout1788A (17) ;
WORKERS'COMPENSATION OKLARAiION APPLICATION FOR PLUMBING PERMIT '
I herebv affi.m�hor 1 hova a cadHica�e of conse��ro seli �yqby�q ' '�
irnure,or a cerrificuta of Workers'CompenEption Insurance, (E 817�REV.10/BI) �� �
w a cerrhied wpy thereoF�Ser.3800,lab.C.) COUNTY OF LOS ANGELES BUIL�ING AND 5 F
i
Dw��EBS�914Rc9.mpo�y Fremnnt TnciPffi17.ty , a(1� i
CeNified copy is Nereby furnished.
FORAPttKAN(70FlLLIN�PRMTORTY7EJ BUftOING
�Cen�fied mpy ia filed w��h rhe coueN bui ing inspec- A���� � j
fiondepanment. �vtl't�eER FiMua�aeir�n� � �E ioeqtm Diamond. Bar .
Dpta �+��Q�PPlitqnl . WATER CLOSET �� L ,
CERTIFICAiEOFEXEMPf10NPROMWORKERS' BATHTUB _ CTtOSSST.� 6O�PL11111 s Ranch 1
[OMPENSATION INSURANCE own�a
sHo�R South CounCr Cor . ;
(Thlf saction noad not be eomplated tE th�work fnvolvsd by �i� i
fhs p�rmlf h!or on�hvnAnd dellan(S100)m�e��•I 2 u+vaTORr noor�u
I certify�that i�rha performonce of�he wwk for whieh rhis . �
permit i�imved,7 aholl no�amploy arry penon in any mooner Sw¢ aiv 7EL.
ao as io become eubjecr ro rhe Waker�Compensallon Laws.
/ DISHWA$HER — �aM��T�R.C.R. Plumbin , INc. �
Dcfe - app�iconl CLOTHES WASHEII . �
\ M^ICE PO APPIICANT: If, afror making�h�s CeniNcata of ��� 12 $ � olia Ave. _ .
� �ption, vou ahouid beeome subjeci ro �he Wakers swiN'Nat�t''°OakECEajoa ei�, �.�.
l,.n pemafion provisions aS tha Lobor Code,yv�mVs�forlh- . �,�,µrry yp�NKtER 575TFM � �
with eomply w1M such proviaiom w��hie permil shalf be ���. 336428 ��aq� C-36
deemed revpked. . WATER MEATFR
110EN5ED CONTF�ACTPRS pECIARATION OISt�nc7 NO. vkOCESSED BV `
I hereby qff'nm tfq/1 om li�ansed�rder prorisio/n of Chapfer 9 GAS SYSTFM WTLETS :
(wmmencing with Secrion 700p)of Dirision 3 of fhe B�siness pUf�ETS R /� . p}, ;
and Prafesim6 Cade.am�my lireme is in fuU 6orm ortjaffed. 5 PERSVSIEM DA� /� y/�y VALI At10N � � �
i
Li<ense N�mber � ��_ ��_lic.Class�� OC ;
' fINAt O ;
co�,.a+o.
RCR Pltmtbin�,,,;, 6/19/85 ev W �
❑ I am exempt undr Sec. y �
e.dr.c.for+ti�s.eoao� plan check fee Z ?
�
oore: 1 7 fl 8 A
VLUMBING PERMl�ISSUiNG FEE j � O O �
s�y�ww.e A�. . • : •5 !
T�TAI fEE 7G�5� ;
' Plon check opplicaM �.r�7 6'5 Q .
� SINGIE FAMILY �� • •7�i 5 0� i
NOME OWNER-BUIIDfR DECIARATION Name R.C.R. PLUMBING INC: �
�. �e6y affirm thof I am exempl from the Contrac�w i License ].2]$5 jKg ol ia Ave.� _ . . �7�2 0 i A S �
for the fol!owing reason(Section 70.91.5,Business ond. Address gTl �
Wofessions Code): �i�y Tal.No.
❑ I,m owner o1�he properly,will do fhe work aMl rhe e � �
. atruU�re is not in�ended ar offmed for sple l`�tion � � ► ;
70I4,Bus�nees and Rofesa�ons Gode). �
CONSTRUCTION IENDING AGENCY � - � � I
I
I hereby offi�m tFqt fhere is a conshuction landing agen[y for '
Ihe performonce of the work fp which this permit ia issued . �
(Sac.3097,Civ.C.).
Lander's Nome
i
tender_'c Addrass j
I cerlify thor I have reod rhis applicarion ond s�are thar rhe ►
abpve infprmplion is cared.I ogeee�o comply with all County �
ord�nances and S�ate Iows regolating Plumbing,and he�eby �
ou�horize represenroiives of this Co�n�y to an�er uDon the ' '
abova•mentioned pro rty for ins tion purpoees. ;
� �, SEE REYERSE FOR EXPLANA70RY LANGUAGE
R.C.R. Bv. Q��►�►�.7[�6/19/R5 '
S�grqluro of Perminee Dale - j
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