HomeMy WebLinkAbout1466A (8)WORKERS' COMPENSATION DECLARATION 1446674
1 hereby affirm that I have a certificate of consent to self cc arr (2-60
Insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.) 5/82
P3 CI956 CPVA Compan Aetna Casualty
Certified copy is hereby furnished.
Certified copy is filed with, a ty uilding inspec ion h
department.
Date Applicant
CERTIFICATE OF F.X PTIO R MWORKERS'
COMPENSA ION 1� URANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars (5100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisinns of the Labor Cade, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Ni p er 142274 Lic. Cis C-36
e i n'f lig-—
Contractor Date
C1[ am exempt from the licensing requirements as 1 am a P'
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg. No. Date PI
HOME. OWNER -BUILDER DECLARATION N
I hereby affirm that 1 am exempt from the Contractor's A
License i.aw fnr the following reason (Section 7031.5, Busi- C,
nese and Professions Code):
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performanceof the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that i have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize represe [egtives of this County to enter Non the
above. tone p�'� for inspec io purposes.
Vz
Si ure b7t,$4. Date
APPLICATION FOR PLUMBING PERMIT
check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
check applicant
ddress
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
FINAL
DATE �� �� VALIDATION
FINAL
BY e _ ,J
A
�1466A
#.....5
1. 3 2 8 5 0
••32a50'.
0204-82
COUNTY OF LOS ANGELES
7 unit
BUILDING AND SAFETY`
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
550 N. Golden Springs Dr
1BER
FIXTURE OR ITEM 4111
FEE
ADDRESS
TY
WATER CLOSET
Diamond Bar
T Sunset Crossing
7
BATHTUB
2T.
I
4
SHOWER
1The
Anden Group
7
LAVATORY
6S
MAIL
629 Covd�na Blvd
W0000NTRACTOR
a
7
SINK
2n
Dimas TEL. No. 599-8491
U
]
DISHWASHER
2CTOR
Pipeline Plumbingo
CLOTHES WASHER
2E
00ADDRESS
12061 Pipeline Ave
w
SWIMMING POOL RECEPTOR
CITY Chino TEL. No627-7501
r1
z
LAWN SPRINKLER SYSTEM
STATE 142274 LIC. C-36
WATER HEATER
2
00
LICENSE NO. CLASS
]
GAS SYSTEM 5OUTLETS
'Z
00
DISTRICT NO. PRQCESSED BY11
check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
check applicant
ddress
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
FINAL
DATE �� �� VALIDATION
FINAL
BY e _ ,J
A
�1466A
#.....5
1. 3 2 8 5 0
••32a50'.
0204-82
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