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Home My WebLink About1733A WORKERS'COMPENSA710N DECLARATION AF�PLICATION� FOR PLUi�ABIN`G PERhl11T n4a�"' /� I hereby affirm that I have a certificate of consent io self �yq��q - -� insure,ar a certifimfe af Workers'Compensation Insurance, CE BI7(REV.WBi) -�� or a cenrfied copy ihereof(Sec.3800,lab.C.) COUNTY Of LQS kNGELES BUILDING AND SAPETY �c1�o33f..-J.aa-�ompany�'YPi11l1T1}' TTIf�PTTlYIlt'y Certified mpy is hereby fumished. � �! � FOR APPLICANT TO FIIL IN(PRHJT pR TVPEJ BUILOING�j/-� Cerfified copy is filed wilh the coonty b�� ing inspeo- ADDR{SS�J / tion depariment. � NUMBER FIXTURE OR ITEM [; FEE . . LOCALITY Diamond. Bar Dote�-/��Appli4onl � WATERCLOSET � NEAREST CERTIHCATE OF EXEMPTION FROM WORKERS � BATH TUB / �. cRoss sT. 60/Philli s Ranch COMPENSATION INSURANCE OWNER SHOWER South Countr C (Thi�sectfon m�d irot be complet�d ff th�work fnvaH�d by . Ih�psrmif i�ior pm hundr�d dolhrs(5100�or Iws.) 3 LAVA70RY � — �'�� ADDRE55 I ceriify ihat in ihe performance of the work for which lhis parmil is issued,I sholl not employ any person in ony monner SINK Lp -- CITY � - TEL.N . ' so as to become s�bject fo the Workers'Compensation Laws. DISHWASHER • COMRACTORR,C.R, Plumbin INc. Dofe Appliconf CtOTHES WASHER t -'� qDDRESS _ f�OTICE TO APPLICANT: If, afier making ihis Cerlificote of IZ M Tl 1� V mption, you should bamme subiecf ta the Workers' SWIMMWGPOOLRECEPTOR . . . , __mpensation provisions of the Labor Code,yau must torth- CITY . . TEL NO _ with com I ih such ovisions or fhis ermit shall be �AWNSPRINKtERSYSTEM - . deemedrevoked. � P WATERHEATER ��ENSENo. 336428 ��q� C=36 _ IICENSED CONTRACTORS DECLARATION � DISTRiCT NO. PttOCE56ED BY I hereby affirm Ihat I om licensed under provisions of Chopter 9 GAS SYS7EM OUTLETS tQ —. � (commencing wifh Se[fion 7000)of Division 3 of the Business OU7lET50VER � and Professions Code,and my license is in 4ull force and effect 5 aea SvsTe�.n FINAI License Number�..�.��$._lic Glass�_ DATE �1' y/'�5 V. II�ATI�N o c' f�./19/85 BY"'`�2�,� � Contractor RCR P�.tIlTL�51n¢ Date � ❑ ua I am exempt under Sec. E.. th> B.BP.C.for fhis reasan Plan check fee '" �a�e� PLUMBING PERMIT ISSUING PEE E Q a `-�� 7�.J A Signature TOTAL FEE ry rj�c • • a •5 Plan check appllcpM � � '�i E 5 Q SINGLEFAMILY .C.R. PLITM$ING HOME OWNER-BUIIDER DECLARATION Name � . INC.. ° 6• ��f`.�'�.v C u � ��eby affirm lhat I om ezempt from ihe Controcfor's License Address ��$��ag21p 13 V E. �ior rhe fallowing reason(Sectian 7031.5, Business and G�,2 4-�� Professions Code): Ci�y � �Tel.N ❑ I,as owner of 1he property,will do ihe work and the struct�re is nof intended or offered for sale (Seclion � � 7044,Business ond Professions Code). � CONSTRUCTION LENDING AGENCY � I hereby affirm thaf there is a canstruction lending agenty for the perfwmanca of ihm work for which this pa�mit is issued (BeG.�Ll97,Ei�.E.J. , � E!R!�ldS I�CPRR rdA�M?.4l�4a^S I certify ihat I have read this applicotion ond state�ho�the � � - above information is mrrect.I agree to comply with oil Coonty . ordinances and Siote laws regulating Plumbing,and hereby authorize representafives of this County ta enter upon 1he . . obove-mentionad pr ry for insp tion purposes. SEE REYERSE FOR EXPLANATORY IANQUAGE R.C.R. B� (�h�% i p�E�/�9�85 Signature of Parminee pate APPROVALS� Da7E i��ec70x53qffA�iUa€ ��R'S hiOT25 OWN@R-�UILDER DECLARATION UNDER SLHB WORK �'� G,��,_ � � I hereby afflrm 7hot I am enampt from the Conhoctor's ROUGH PLUMBING / License Law For the following reason (Sec�ion 703L5, GAS PiPMG y Buslness and Professions Code):Any dfy or rovnty which GAS V@FIT requires o permif to construd,alter,improve,demolish HOT WATER HEATER or repoir cny strudure, prior to ils issuance, also re- qvires tMe upplicewt lor suth perrrait fo f�fe a signed stale- PLUMBtNG FfXTURES � ment fMet he is lieensed purwanY fo fhe provisions of Ihe GAS TEST ..J, Confrcctor's License Corv(Clwpter 9(tommencing wifh UTILRY CO.NO71FtED ' Sec7iosr 7W9)oI DiviSfon 3 of tYw BusiFless atd Profes- s ians CodsJ or fhW ke is exaenpf tborefrom ortd fFe basis lor fhe ollegsd exempfion. kny VIOIOtIOA oi Section FINAL ��on �ronf 7031.5 by ony applicant lor u permif subjects fhe appli- cant to a civil penalty oi nvt mure�bor. �ive hundred dollars(5500).: INDUSTRIAL ❑I,as owner of ihe proparty will do The work,and WASiE APPkOVAL - ihe s�ructure is not intat�ded or offarad far sale. (Se¢.70I4,Buslnesa ond Professions Code: ihe G ^�o- - . ., tar's tic�r::se Law does naf app7y fo ae awner o#prorarfy . who bviMs or Improv�s ihsreon, and who does such ' � ' � work himsa!#provld�cl iha�s�cR irnprowmanls are nof - intended or offe�ed for sak.if,however,tha buUding o�� — Irnprovern«rt Is seld w71Mn ons ysw of eompfeeion,thc , ownervbWfd�r wiN have�f�o b�uden of pro�ing thut Fe did � not 6uild or improve for tho purpose of sale.) I am exempt under 3eE. , � B 8�P.C.for this reason Date OWner IhdSi�CTOfv'S h�1�7TES —