HomeMy WebLinkAbout1462A (13) WORKERS'COMPENSATiON DECLARATION >�4s{)A �
I herebY affirm th�� I have a tertifitate o<<o�g�,�.�0 5e�� �E.,,,=-.o, APPLICATION FOR PLUMBING PERMIT ..
insurc,or a certiticate of Workers'Compensallon Insurance,or . . .
a certified copy thereof(Sec.3800,tab.c.) COUNTY OF LOS ANGEIES BUILDING AND SAFETY �
�6�.�y��56496 CPq�oV p�ny Aetr.�; 5/82 ; uni t •
� Certified copy is hereby furnished. FOP APPLICANT TO FILL IN(PRINT OR TYPE) qDDNESS 530 N. Gol den Spri ngs Dr
� Certified copy is filed with t coun uil 'ng inspectio� NUMBER FIXNRE OR ITEM � FEE LOCALITV
�e�a«men�. �� WATER CLOSET 6 00 D1dR10nd BdP
Date Applicant NEAPEST �
� BATHTUB `Z QQ CROSSST. SUI�S�et CI�OSSIII �
CERTIFICCOM ENSATI N iNSU AIVCEORKERS' 4 � OO THE AN[�F.N GROUP �
` SHOWER OWNER .
LAVATORY MAIL
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(This secGon nced not be completed if the woik involved ADORESs 629 Cov�na B1 d �
by the pertni[ is frn one hundred do0ars (5100)or leas.) SINK . 'L �Q CITY San. Dimas re�.n,o599 8491 V
1 cen�(y ihat in the performance of the work for which this 7 p�SHWASHEft Z QQ CONTRACTOR P1pe �ine Ufli ng � o �
permit b isaued;I shall not empioy any person in any manner
so as to beeome subJect to the Wnrkera'Compensation Lews. � CLOTHES WASHER 2 �Q ADDRESS � U
� Date � ApDlicant SWIMMING PDOL FECEPTOR d
NOTiCF,TO APPLICANT:If,a(ter making ihis Certiflcete af CITV Chino TEL.NO. 62J�7�JO� �
Lxemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE 7 L10. ?
Com;e^saticn p:o�•isions of thc Labor Code,you must Gxlh• yyqTER HEATER LICENSE NO. 14ZZ74 � CLASSC-3E)
with compiy with such provisions or thls permit sheli be 7 2 0�
deemedrevoked. � 7 GASSVSTEM 5 OUYLETS Z oo DISTRICTNO. VR CESSEDBY
LTCENSED CONTRACTORS DECLARATION OUTLETS OVER �O U,e.efti� .
I hereby afCrm ihat I am licensed under prnvisions of Chapter 5 PER SVSTEM �
9{commencing with Section 7000)oLDlvision 3 nf tbe Buei- - --� - FINAL -� - � � � � � - - -� � �
...._. _.._. .............. -�. _ -
ness and Professions Code,and my license is in Cull force and OATE �� p� VALIDATION
effect.
C-36 FINAL �
License Number �4?Z7Q Lic.Clnsa gy �
co�tra�tor Plpell►Ie P1bqDBte �-Z8-82
�
� I am exempt from the ticensing requirements as 1 am a Plen Ch2ck fCe - 5O
licensed archifect ot a reg�sfered professional engineer pLUMBING PERMIT ISSUING FEE S�
acting in my professional capacity(Section 7051, Bus- .
iness and Professions Code). TOTAL FEE .
Lic.or Reg.No. . Date Plan chock applicant . .
HOM6 OWNER-BUILDLR OGCLARATIDN Name . ' �� ��2:A :
Address �� �'��• •Jr
1 hereby nffirm that I am exempt from Ihe Contractor's �
License Lo�v tor the follow'ing reason(Sec�ion 7031.5,Busi• C(ty TM.No. � ��•3 2 8 5 0
ness and Profecsions Code): �
� 1,as owner of the properly,am exclusively contracking •��3 2&5,0 v
wilh licensed contracton to conslruct ihe project . ' ;
(Section 7044,Businas and Professions Code). , - O 2 O A"$2
CONSTRUCifON LENDING AGENCY
I hereby affirm Ihat there is a construction lending agency
for the performance of Ihe work for which IMs permit is
issued(Sec.3097,Civ.C.).
Lender's Name �
Lender's Addrcss .
I certify that 1 have read this appllcatian and state that the
above inPormation is correcL I agree to comply with all County SEE REVERSG FOR EXPLANATORY LANGUAGE - -
ordinances and State laws regulating Plumbing, and hereby •
authori repre ntatives of this County to enter upo the
abo�-me tlo ro rty for inspection purposes. ' -
/ �
' nature o tee Date
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