HomeMy WebLinkAbout1289A WORKERS'COMPENSATION DECLARAT[ON ��was�w
[ hereby a(Rrm ���,� , ha�r a'certificateo��o�b�<<o8e�f �E.�„�..e, APPLICATION FOR,PLUMBING PERMIT . �
insure,ona certiflcate af Workers'Compensation Insur;pce,or �-
eoC(Sec.3800.Lab.C.) �/�T � .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po����_11�p°��� p 5�83
� Certified copy is hereby furnis ed. , FOR APPLICANT TO FILL IN(PRINT OR TYPE) BU�LDING
. � Certified co y is filed with the county buildin NUMBER FIX7URE OR ITEM. • FEE ADDRESS 980 N. Gol den S rl n s Dr .
p g inspection
�iepartment. LOCALITY Di amond Bar
Date ADC��cant �] WATER CLOSET NEAREST
� BATHTUB cRosssr. Sunset Crossing - �
CERTIFICATE OF EICEMPTION FROM WORKERS'
COMPENSATIONINSURANCE SHOWER OWNER The Anden Grou
LAVATORY MAIL
(ihis section need not fie com leted if the work involved �� ADDRESS a
ny tne permit is [or o� hun�.� donus (sloo)or tesa) � SINK ciTv San D1mas re�.No.599-6864 �
1 ter�ity tha[in the perfarmante nf the work fo�whith thi5 OI5HWASHER �� �
permit is issued,I shall n�t employ any person in any manner CONTRACTOR p; el i ne Pl umbi n � "
so as to become subject to Ihe Worker�'Compensation Laws. � CLOTHES WASHER ADDRESS .� U .
Date Applicant SWIMMWG POOL RECEPTOR W �
NOTICE TO APPLICANT:If,after making this Certificate of CITV POIflOtld Ca rE�.No.623-1437 N .
IixemD��on, you shautd become suhject tn the Workers' LAWN SPRINKLER SYSTEM STATE � LI0. z �
Compensation prm�isions of the Labor Code,you must forth- 7
with comply with such provisions or this permit shal� be
] WATER HEATER l.� O LICENSE NO. 14ZZ7�I CLA55 C-36
deemed revnked. �ISTRICT NO. PROCESSEO BY
GASSYSTEM OUTLETS '� �nn (�
LiCENSEDCONTRACTORSDECLARATION pUTLETSOV R �, �y,�j� �
I hereby affvm that I am�icensed under prnvisions of Chapter 5 PE R SYSTEM
9 (eommencing with Section 1000)ot Dicision�of the Rusl• � � FINAL �f//�/�3 ' VALIDATION
ness and Prntessions Code,and my license is in full force and DATE �
effect.
License Number 142274 Lic.Class C-36 FINAL � .
BY
CoPtr�cto?���1"� Dete�$-$3
� I am exempt from the licensing requirementa as I am a Plan check fee
licensed architect or a registered p�ofeasional engineer PLUMBING PERMIT ISSUING FEE$ 5Q
aciing in my prafessional capacity(Section 7051, Bus• .
iness and Yrofesaions Cnde). TOTAL FEE
Lic.or Res.No. Date Plan check aOPltcan[ �r� 2 B.9 A I
IiOME OWNLA-BUILDER DECLARATION Name . ' ' �
�. . . . .5
i hrreby affirm thst I am exempt from the Contractor's Address
l -49Q5�
License Law fot ihe foliowing reason(Section 7031.5,Busi• City Tsl.No. � � � � '
ness and Protessions Code): •�•(«9 Q 5 0�
� I,as owner o[the property,am exNusively conGacting . ' � ' � �
��ith Iicrosed contrectors lo construct the project 0,1,2 7_�(�
(Section 7054,Business and Protusions Code).
CONSTRUCTION LENDING AGENCY . .
I hereby af£rm that there is a construction lending agency ,
for the performance ot the work for which this permit is
issued(Sec.3097,Civ.C.). �
LendePs Name
Lender•s pddress �
I certify Ih 1 have ad thls apP�icallon and state that the �
ahove infor 'on is c rect.I agree M rnmply with all County SF,F.REVERSE FOR EXPLANATORY LANGUAGE � �
ordinances � tate aws reguiating Plumbing, and hereby .
authorize r p ntativ s at this C "to enter upon Ihe '
above-mC rope y fo ' pection purposes.
a _
Si Nermittee Date ' � _
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