HomeMy WebLinkAbout1463A WORKERS'COMPHNSATIONDECLARATION vswasow �
� he«oy arf+�m Ihat I have a'certiCcate of�o�5�,� �ose�< <E.,,,=-.o, �APPLICATION FOR PLUMBING PERMIT
insuro,or a certificate ot Workers'Compensation Insurance,or �
a certified copy thereof(Sec.38D0,Lab.C.)
Q' C� 956496 CPAV Aetna �dSUd�ty COUNTV OF lOS ANGELES BUILDING AND SAFETY
Froyicy o. Company . � .
� Certified copy is hereby furnished. g� .
FOR APPI.ICANT TO FILL IN fPRINT OR TVPE) BUILDING
� Ce�tified copy it fiied wit the co ' ing inspe i NUMBER FIXTURE OR ITEM • FEE AooRess 520 N. Gol den S ri n s Dr
�1eDartment. _ LOC.4LITY
WATER CLOSET 1 Il
Date Applicant NEAREST
CERTIFICATE OF E P710N/ M ORKERS' BATH TUB CROSS ST. ' '
COMPENS IONIN3URANCE !� SHOWER OWNER 1
16 00 The Anden Gro��
LAVATORY MAIL
(This section need not be completed if the work invnived ] A�oRESs 629 Covina Blvd- �
by the permit is for one hund:ed dotlus (5100)or less.) � SINK 28 �� ��TY San Dimas TE�.No.5gg g4g1 °'
I certify that�in the perfnrmance of the work for which this ] DISHWASHER 28 00 P O
permit is issued,[sheli not employ any penon in any manner CONTRACTOR
so as to become subjrct to the Workers'Compensation La�vs. � CLOTHES WASHER 28 00 � AooAEss�p061 Pi pel ine� Ave o
'Uate Applicant � F—
SWIMMING POOL RECEPTOR
N07ICE TO APPLfCANT:IC,atter making this CerliFcate�t CITY Chino TEL.NO.�jZ�—��jO� W
F.xemption, yoo should become subject to the R'nrkers' LAWN SPFiINKLER SVSTEM a
Compensatlon provisions ot the Labor Code,you must forth• LICENSE NO.i4ZZ74 ��S �C-36 �
with comply with such provisions or this permi[ shatl be WATER HEATER _
deemed revoked. � GAS SYSTEM�j OUTLETS Z$ oO �ISTRICT NO. P OCESSED BY
LICENSEDCONTRACTORSDECLARA7fON OUTLE7SOVER I� �(L,f.ct��
I herehy affirm that[am licensed under provisions of Chapter 5 PER SvSTEM
-�9 (commencingwith Section 7000)of Divislon 3 of the Ausi• FINAC y /� �� � � VALIDATION
ness and Rofessions Code,and my Iicense is in full force and DATE (yp
e((e[t.
142274 C-36 BY A� , ,?�L,i,
Litense Number Lic.Class
Controt��peline Plbg Datel/28/82
� I am exempt trom the licensing requirements as 1 am a Plan check fee 8 5Q
licensed architect or a registered profeaaional engineer pLUMBING PERMIT ISSVING FEE S
acting in my profe55iOna1 CapaNty (Section 7051, Bur
iness and Prnfessiona Code). TOTAL FEE
�1463A
Lic.or Reg.No. Dafe plan check applicant
HOSILOWNGR-BUILDERDECLANA7fON Name �:� �.� � �.`� �
I hereby aff¢m ihat I am exempt from the ConiractoPs
Address �� •32Q50 �
License Law for the foliowing reason(Section 7031.5.Busi- City Tel.No. � •3 G a,rj�� '
ness and ProRssions Cnde): � • �
� I,as awner of the property,am exclusively contraeting 0 2��l�8 z � �
wilh licenud contractors to rnnshuct ihe project
(Section 7044,Business and Profasions Code). ,
CONSTRUCTION LENDING AGF.NCY - . .
I hereby aCfirm ihat Ihere is a construction lending agency
for the performance of the work for which this permit is �
issued(Sec.309T,Civ.CJ. � - -
Lendet's Name
Lender's Addr?ss
f certify that I have read this application and state that the �
above information is correct.I agree ro comply with all County SEIi RL'VERSE FOR LXPLANATORY LANCUAGE - - - � �
ordinances and State la�vs regulating Plumbing, and hereby �
authori�e repr ntatives of this County to enter upon the �
a6ove enti d pr erty far ins ection purposes. �
O�_ .
nature } r ittee Date
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