HomeMy WebLinkAbout1756A WORKERS'COMPEN5A710N DECLARATION APPLIC/�►TION FO�R PLUMBi�IVG PE1�MIT �
I hereby affirm ihat I have a cerliticate of mnsent fo self �bqbg�q �
inwre,or p cerfificate of Workers'Compensation Insurance, CE 877(REV.1�/81)
or o certified copy fhereof(Sec.3808,Lab.C.) COUNTY OF LOS ANGELES BUILDING ANO SAFETY
P�ol�cy�dE�2].�$9Companv F'�'ER1CLt TnrlPmn].ty . �/ O /�
CerYified copy is here6y furnished.
.� FOR APPIICANT TO Flll IN(PRINT OR TYPEj OUIL�ING`7 C/ 7—�"�
.Certified copy is filed wilh Ihe county buii ng inspec- ADDRE55�1 ! /
liondeparimenl. NUMBER FIXTURfORITEM �i FEE �QCALITV Diamond. Bar
Date��.�.5._Applitont WATER CLOSET
NEAREST
CERTIfICATE OF EXEMPTION FROM WORKERS' BATHTUB �- CeO555i.� F)O�PYLllll� 3 Ranch�
COMPENSATION INSURANCE SHOWER OWNER SOUtYl CO Tl
(ThH��c�bn n�ed nat b�eomplN�d if ih�werk involved by Mnil - �
fhe p�rmN i�for on�hundr�d dotlorc(;}00j or I�ss.) lAVA7ORV ADDRESS
I certify Ihat in the performance of the work for which this
permit is issued,I shall not employ any person in any manner S�NK Q7Y - TEL NO
so as to become su6ject to the Workers'Compensation law5. DISHWASHER •
CONTRACIORR.C.R� Plumbin INC.
Date Appli[pM � CLOTHESWASHER ADDRE55
�'QTICE TO APPLICANT: If, oftar making this Cerrificate of SWIMMINGPOOLRECEPTOR
- oplion, you should hacome subject lo ihe Workers' CITY � ' 7E1.NO.
��,npensation provisions of the Labor Code,you must forth- LAWNSPRMKLERSVSTEM —
with comply with-such provisions or this permit shall be STATE • • LIC.
deemedrevoked. W'ATERHEATER ���ENSENo. � 336428 CLA55 C-36
LICENSED CONTRACTORS DECLARATION �ISTRICT NO. � PROCESSED BV
I hereby affirm Ihaf I am(icensed under provisions of Chapter 9 GAS SY57EM J� OUTLETS �
(commencing with Section 704)0)of Division 3 of the Business OUTlET50VER `'
and Professions Code,and my license is in full force and effect. 5 PER SVS7EM FINAL �
DATE. I+L/G-�b'� VA ATION d
license Number��.Q.�.�,_Lic.Class�� �,.�..
FINAL y��,�7 _ ` Q
� Contratlor RCR� P LUIl1171riQ Daie 6/19/85 . sv //"""fi2+f^�"'� V
❑ k.S
I am exempf under Sec. [a,
c+�
B.BP.C.for this reason Plan check fee � ""
Date: pLUMBING PERMIT ISSUING FEE$ v O
Signature �� 7�6 A
� TOTAI FEE �'7/,��
!lQ �`� • s�,��5
SINGLE FAMILY Plan check applicant � • .7 Q 5 O
HOME OWNER-BUIIDER OECtARATION Name R.C.R. PLiTMBING� . INC.. ,
f LL'�'eby affirm Ihot I om exempt from ihe Contrac�or's litense Address agno 3 . VE'.� •�' •7 6,Jr�u
�for the following�eason (Section 7031.5, B�siness and
Professions Code): Ciry � Tel.N�.�� 0 7.�9�+8 5
❑ I,as owner of ihe properly,will do ihe work ond the . �
. slrucWre is not infsnded or o$erad for sale (Sec}ion �
7044,Business and Professions CodeJ.
CONSTRUCTION LENDING AGENCV
I hereby affirm Ihat Ihere is a construction lending agency for
iha performa�ce of�he work for which this permif is issued
(5e�.�.Cir.C.).
� Lender's IVtrma
lerd�'s/Sdtlle�, �
I certify ihat I have read this opplimtion pnd stote that the �
above information is correct.I agree to comply wilh all Counry
ordinonces and Staie laws regulating Plumhing,ond here6y �
authorize represenlatives of this County to enter upon the
above-menlioned property fo�ins Uion purposes.
f SEE REVERSE FOR EXPLANATORY lAN4UAGE
R C F. ��- ,Q t ,�i o{+
Signoture of Pe$i�1ee�� ���afe �� �
aPPROVAiS DA I S�CrOre'SSiGµp7Uke ���CTOR'SNOTES OWN�r2-6UIlDERDECLARFTION
UNDER SL49 WORK ,f' S �At.ty�_ I here6y affirm that I am exempt from lhe CoNrocror's
RbUGM PY.UMBiNG ,q � ��4. LkensA Low for ihe following reason (Se:licn 7037.5,
GAS PfRikG _,(, �j� fiusiness and Profession,CodeJ:Any cify or county,which
G.454lNT reGwres a permif to cons}ruct,alter,improve,demofish,
or repair ony,sfrutiure, priar fo ifs issuance, olso re
HOT WATER HEA'fER — , qWres�he opplicontfor suth permil to fifeastgnedstaVe-
f'LUMBMJG FIXTURES � � ' � � � men�fhet fie is/lcensed pursuanf to�he provisions of ti�e
GAST@6T 4� Confracfcr's Licerrsa Law(Chapter 9(commencing wifh
4
� - Section 7p00)of DiWslaa 3 of thr 8usineee ond Profes-
UTILITY CO.NOTIF;ED
.. . . siorrs Code)or}ha#Fre is exefttpt thereirom orrd the kwsis
c�7 � lor �he ofleged exempl;on. Any vlolafion ot Sectlon
PINAL ��er on _iion� . 7031.5 by any opplicont for o peemit subjeefs ihe appli-
, canl to a clvt(penalty of not more than five hundred
dollars(SSt1G).:
INDUSPkiAL � ❑1,as owner of ihe propsrry will do the work,ond
WASTE APPROVAL � � ihe sfrutture is not inlended or Offered for sale. —. -
� (Sac.704E.Buainess undFkofesslo-ats Code: ihe C io
� . � . fur's Uaenae Law daos not opply ta on ownsr o1 prorerly
� � � �� � � . who Mtifds o�lmprores 1Mreon, and who does such
" work hlmsel!provid�d�haf such Improwmertts wa not
lnfended or offsred for sale.If,howsver,fiie 6uUd�ng or
- lmprovemen!is sold wi}hvn ons year of com�lefion,ihe
owner-bu(Ider w'�!1 have the bwdrn af proving tha}hr did
� not!wild or improve for ihe purpose of sale.) �
I am exempt under See.
6&P.C.for this reason
,j Date
• Owner
Ild�PECTOR'5 NOTE3
i