HomeMy WebLinkAbout1464A (15) WORKERS'COM1IPENSATiONDECLARATION � f�ase�w � APPLICATION FOR PLUMBING PERMIT {�
I herehy affirm that I have a'cerlificate of conset�t to self ce si�It-ee
insure,or a certificate of Workers'Compensation Insurencq a� _ ��
a certiCed copy thereof(Sec.3800,Lab.C.) � � �� '
�!�8C�CK956496 Aetna CaSUB�ty � COUNTY OF lOS ANGELES BUILDING AND SAFETY� •
Phlicy o. Company
� Certified c�py is hereby furnished. 5�82 FOR APPLICANT TO FILL IN(PRINT OR TYPE) gUILDING . '
NUMBER FIXTUREORITEM � FEE 'O'DDRESS 510 N. Golden S rin $ �l'
� Certified copy is fiied wit he c f bu'ding Inxpeclio LOCALITYD�dlflOtld BdP
department. WATER CLOSET
Date AppliCant NEAREST
!� BATH TU9 �6 Q� CROSS ST. ' ' �
CERTIF[CATE OF EX TION OM ORKE S' SHOWER �� The Anden Grou �
COMPENSA fONIN RANCG Z OWNER
(This SecNon need not fie completed if the work involved �AVATORV � ADDRess 629 Covina�Blvd a
hy the permit is for one hundred dollars(5100)or tess.) 4 SINK �6 OO cirv TEL.NO �
San Dimas. 599. 8491
I cerlify thaf in the performance of ihe work fo�which thls 4 OISHWASHER � QD coNTRaeTOR Pi pel i ne P1 umbi ng �
permit is issued,[shall not empiqy any person in any manner -
so as to become subjett to ihe Wotkers'Compensation Laws. � 4 CLOTHES WASHER - �G OO ADDRESS �206 pe ne '�e w
Date Applicant � SWIMMING POOL RECEPTOR a
NOTICG TO APPLICANT:If,after making th(s CerHficate of CITV t,� 7EL.NO _ tn
Exemption, ynu shouid become suh'ect to the N'orkers' LAWN SPRINKLER SVSTEM • _ z
Compensalion provisions nf the Labor Code,you must fnrth- 4 yrpTER HEATER � OQ L C NSE NO. �42Z74 CL ssC-36
with comply with such provisions or this permit shal! be DISTflICT NO. PROCE5SED BY
deemed revoked. Q GAS SYSTEM 5 OUTIETS � �� �
LICENSED CONTRACTORS DBCLARATION ' OUTLE7S OVER �0 ��u��C/
I herehy afl7rm thal 1 am Iicrosed under provisions of Chapter 5 PER SYSTEM _ _ ___
��9(commencing wilh Section 7000)of Divisinn�3 of iht Busi- �- ��� -" �'" � "'" � � � - FINAL - �� �� � �� � ��
ness and F'rofessions Code,and my license is in Cull fotce and DATE •> �[r a'/�
VALIDATION
effect.
FINAL
License Num6er���Q.ie Class ��� BY
ContractorPlpellne Plbg D,,�1/28/82 u � .
� I am exempt fmm the licensing requirements as 1 am a Plan eheck fee 5
licensed architect or a registered professional en&�neer pLUMBING PEFMIT�SSUING FEE$ �g 5� -
acting in my professional capaeily (Section 7051,Bus- '
iness and Rotessinns Code). TpTAL FEE
Lic.or Reg.No. Date Plan check appllcant
IiOMG OWNER•BUILDER DECLARATION Name �1 4 6 4 A � :
I hereby affvm that I sm esempt irom the Contractor's Address �i�• • • •�•Jr
License Law for the following reason(Section.7031.5,Busi• City Tel.No. ' J . 1 9 2 5 0
ness and Professions Cndn):
1 f,as owmer o(the property,am exclusively contncting •,• 1 9 2 5 0 c=o
� with licensed contractors to construct the project
(Section 7044,Businas and Professions Code). O 2.O�l�eg 2
CONSTRllCTtON LENDING ACGNCY '
1 hereby afCrm thet there is a consiruC�ion lending agency
for the performance of Ihe work for which this permlt is -
issued(Stc.309�,Civ.C.).
Lender's Name
Lender's Address �
I certify that f have read this appiication and state that ihe
above informetion is correcA I agree to complY�+'ith all County SEG REVERSE FOR EXPLANATORY LANGUAGE -
ordinances and State laws regulating Plumbing,and hereby .
authorize repres tetiv s of this County to enter apo'the ' _ _
ah�ve�men bn� !y tor 1 pection purpases.
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