HomeMy WebLinkAbout1291A WORKERS'COMPENSATIONDECLARATION 1�A�i)A � APPLICATION FOR� PLUMBING PERMIT �
I hereby affirm that 1 have a�certificate of consent to aelf ee an(z-so � •
insure,`br p certificate ol Workers'ComDensationCl'n�ra ce,or � . . '
a certi�ied c2,Cy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUI LDING AND SAFETY
A1 �3 1 '��an� '
� itified cnpy is hereby farYsh . 5�83 FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUIL�ING
ADDHESS 960 N. Golden 8 rin s D �
� Certified copy is fiied with the county building inspection NUMBER FIXTURE OR ITEM • FEE
�lepartment. LOCALITY Diamond Bar
. WATER CLOSET O
Date Applicant NEAREST ,
] BATHTUB CROSSST.SI1►ISQt C,T`()S$�ri � �
CERTIFICA7E OF EXEMPT[ON FROM WORKERS' .
CO'`tPENSATION INSURANCE SHOWER OWNER
LAVATORY MAtL 629 Cov9na Blvd }
(This section need not be completed if the work involved � nooqeSS � .
by the permit is for one hundred dollars (5100)or taa.) 7 SINK ctTv San Dimas TE�.No. 599-6864 V
I certify that in the pertormance of the work fnr which this � DISHWqSHER CONTRACTOR P� el ine Plumbin O �
permit is issued,I shall not employ any person in any manner
so as to hecome subject lo the Workers'Compensalion Lawe. � CLOTNES WASHER O AODRESS�O4O W.Seeond St � c~i
Date Applicant SWIMMING POOI RECEPTOR pW.
NOTICI:TO APPLICANT:If,after making this Cer�iFcate of CITYPO(�jOna � TEL.NO. 623��437 N
Exemption, yau shovld hecnme subject to the Workers' LAWN SPRINKLER SVSTEM STATE 1 LIC. z
Cnmpenc�tbn provisior.s of!ha LaEor Code,you must forth-
with comply with such Orovisions or this petmit shatl be 7 WA.TER HEATER '� O LICENSE NO. 142Z74 CLASS c-36
deemed revoked. � GAS SYSTEM 5 OUTLETS 2 �ISTRICT NO. PHOCESSED eY .
LiCENSED CONTRACTORS DECLARATION � OUTLET$OVER , ' �Q
I hereby aifirm that I am licenud under provisions of Chapter 5 PER SYSTEM �
9 (commencing w•ith Section 7000)of Division 3 of the Busi• FINAL �/ry G3 VALIDA710N
ness and Nrofessions Code,and my license is in full force and DATE 7S o ,
effect.
Licrnse Number l���a Lic.Class ��36 BY AL '
contractor Plumbing pate 2'28-83 �
� I am exempt from the liceming requirements aa I am a Plan check fee '
Iicensed architect or a registered professional engineer pLUMBING PERMI7155UING FEE 5 5�
acting in my Drofessional capacity (Section 7DSl, Bui• �
iness a�d Profassions Code). TOTAL FEE .
Lic,or Reg.No. DatE Plan cM1eck appllcant
HOM£OWNER•BUILDER DECLARATION Nama �1 2 9.i�A .
Addresc
1 hereby atfirm that 1 am exemp[ trom the Controctor's �� a o 0 0 5 .
l.icense Lsw for the foltowing rcason(Section.7031.5,Busi- City Tel.No. .
ness and Prntexsions coae): I •4 9 Q 5 0
I,as owner of the property,am exciusively contractinQ
with Iicensed contractors �o construct the pmject . • •4 9 Q 5 0 c=.� '
(Section 704i,8usiness and Pro(essions Code). � �
01.e7-84
CONSTRUC77�N LFNDiNG AG�NCY .
I hereby at�rm that there is �construetion lendin�agency
for the performance of the w�ork for which this permit ia ,,
issuea�sec.so9�,c+v.c.).
Lender's Name
Lender's Address
I certify that I hnve read ihis application and state thaf the "
abo�•e inf ation i orrect.I sgree to comD�Y'n'�th atl Counly SEE REVERSF.FOR EXPLANATORY LANGUAGF. �
ordinance. Sta laws re u Plumbing,and hereby '
authoriz pr 'ves is County to eMer upon the
above- n n ro forinspection pu oses.
S' ature f Permittee Dat
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