HomeMy WebLinkAbout1467A � WORKERS'COMPENSATION�ECLARATION �ar�aw � � -
.I hereny er�.m thet I have a'certifiCate of�o��<<o5e« �e.���,..o, APPLICATION FOR PLUMBING PERMIT
insure,or a cettificate of Workers'Compensation Insurance,or � .
�ett�r� c DX�4rg ot(Sec.380 Lab.C.)
�o (.K��� LF'YH lYetna 5/82 COUNTY OF LOS ANGELES BUILDING AND SAFETY. ,
Policy No. Company � - '
� Cettified copy is hereby turnlshed. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
AD�RE55
� Certified copy is filed with t co y bui ing inspec[in NUMBEF FIXTURE OR tTEM • FEE
department. 1 WATER CLOSET LOCALITV i . � •
Date Applicant r� � NEAREST
BATHTUB CROSSST.SIJ�ISEEt CI"DSSIfI � �
CGRTIPICATC OF EX PTION M ORKERS' �
COMPENSATIONIN� ANCG L4 SHOWER 6 OO1 OWNER
LAVATORV MA�� 629 Covina Blvd
(7'his aecNon nced not be compleled if the work involved �� ADORESS }
by the permit is for one hundred doRus(5100)or less.) ] stNK 2$ 0� ci7v San Dimas . rE�."o5998491 a
O
1 certify that in ihe performance of the w�ork for which this DISHWASHER V
petMit is issued,1 shali not emptoy any persnn in any mannet � CONTRACTOR P� el i ne Pl umbi n
so as to become subject to the R'orkers'Compensatton La�vs. � CLOTHES WASHER 28 �� ADDRESS 12p6� F i el i ne �V2 �
Date App�icant SWIMMING POOL RECEPTOR (~j
NOTICE TO APPLICANT:If,aRer making this Certificete of CITY China TEL.N06`��—�rjO� W
I:zemDtion, you shouid hecome subject to the Workers' LAWN SPRINKLER SVSTEM STATE LIC. N
Compensation provisions of the Labor Code,you mus[torth- LICENSE NO. � �42ZJ4 CLASS C-36 Z
with'comply with such provisions or thix permit shall 6e ] WATER HEATER —
deemed revoked. DISTRICT NO. � PR ESSED BV
� GASSVSTEM 5 OUTLETS 28 OO
/
LICENSBDCONTRAC'fORSDF,CLARAT[ON OUTLETSOVER �O ������ �
t hereby affirm that 1 am licensed under provisions of Chapter 5 PER SVSTEM
� 9(e�mmencing wifh Section 7000)of Division 3 of the Bus1= ' FINAL " ` �/�/� ��� VALIDATION
ness and Prnfessions Code,and my Iicense is in full Porce and DA7E (Q �/
effect.
�4'2'274 C�,36 FINAL .
License Number Lic.Cisss - BV
Bipeline Olbg 1/28/82
Contractor Date
� I am exempt from the Iicensing requirements as I am a Plan eheck fee � 8 5Q
Hcensed architett or a regiatered professionel engincer pWM81NG PERMIT ISSUING FEE S 328 50 �
acting in my protessional capacity (Section 7051,8us-
iness and Protesaions Code), TOTAL FEE .
Lic.or Reg.No. Date Vlan check applfcant �
HO!+fE OWNER-BUILUL•It DECLARATION Name �.
1 herehy affirm that [ am exempt trom the Contractor's Add�BM z� 4�7 A �
License Law for the Pollowing reason(Section 7031.5, Ausi• C�ty Tel.No. �• •�• • •5
ness and FRofessions Code):
� l,as owner of the property,am exdusiveiy rontracting - - - � � •3 2 8.5,0
with Iicensed contractors to ronstruct the projecf .
(Scetion 7066,Business and Pmfccsions Code). � • •3 2 8.5 0� �
CONSTRUCTION LENDING AGENCY � O 2 O�!�H 2
I hereby atfirm that there is a construction lending aeency � �
for the performance of Ihe work for which Ihis permit is . ,
issued(Sec.J097,Civ.CJ.
Lender's Namr
Lender's Address �
1 certify that I hflve read this applica�ion and state that the
above intormatlon is correct.1 agree to compiy with all County SEE RF.VERSL FOR EXPLANATORY LANGUAGE � - �
ordinances and State la�vs regulating Plumbing,and hereby
authoriz reprcsentatives of this County to enrer up n the
above e tio pro erty for inspection purpose i
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