HomeMy WebLinkAbout1288A (6) woRtcres'COMPENSA7fONDECLARATION ��•�•�� , APPLICATION FOR PLUMBING PERMIT {�
[ hereby atfrm ihat 1 have s certificate ot consent to seif es�n(z-ao
Insure,or a certifica�e of Workers'Compensaiion f �ur n ypT . �� .
a c � ((Sec.3800,Lab.CJ rf
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic�1-./tn�/ Cnm an���� �
� Cert� ed c1��er`b�f�5tsl�ea. 5�83 FOR APPLICANT TO FILL IN(PRINT OR TVPE) pDDRE55 990 N. Gol denSprings Dr
� Certified copy is fi�ed with the county buiiding inspection NUMBER FIXTURE OR ITEM • FEE
Aepartment. O LOCALITY Diamond Bar
Date AppiiCant �NATER CLOSET NEAREST �
7 BATHTUB cAosssr. Sunset Crossing �
CF.RTIPICATC OF EXLMPTiON FROM WORK£RS' � '
COMPfiNSAT[ONINSURANCE SHOWER owNEafhe Anden Grou
LAVATORY MA�� } ,
(This section need not be completed if the work invoWed ] � ADDRESS j °�
by the permit is for one hundred dollsrs (5100)or less.) � SINK San Dimas 599-686 O
Z CITY TEL.NO. U
1 certify that in the pertormance of the work for which this DISHWASHEF �
permit is issued,!shall nnt employ any person in any menner CONTHACTOR P1 1 in P b1 �
so as to become subJect to the Workers'Compensation Lawa. � CLOTHES WASHER • � � Z AODHESS�O4O W.Second St �
Date ApDliCant SWIMMING POOL RECEPTOR �-
NOTICE TO APPLICANT:lf,atter making this Certi�cate af ��TV Pomona Cd TE�.No.623-1437 Z
Gremptlnn, ynu shnuld hecnme suhJect tn the Workers' LAWN SPRINKLER SYSTEM STATE A LIC. —
. ComDensation provisions of ihe Labor Code,you must forlh- yyqTER HEATER LICENSE NO. �4ZZ7Y c�As�-36
with comply uqth such provisions or this permit shali be
DISTRICTNO. PRO�EDBY
deemed revnked. � GAS SVSTEM 5 OUTLETS Z rv�
LICENSCD CONTRACTORS DECLARATION � OU7LE75 OV ER I�l �
I hereby a(firm lhat I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing w•ith Section 7000)ot Divislon 3 of the Rusi- FINAL VALIDATION
ness and Professions Code,and my license is in full force anJ DATE 7 �8 c��
effect. � , _
License Number �a��7a Lic.Class
r�3G BY AL �
Contractor Pi pel i nePl bg Date z-28-83
� I am exempt from the licensing requirements as I am a Plan check fee
ticensed architect or a registered Drotessional engineer pLUMBING PEFMIT ISSU�NG FEE$
acting in my professional capacity (Section 7051, Bur
inets and Professions Code). 70TAL FEE 3 �
Lic,or Reg.No. Date Plan chack applicant O
IIOMG OWNER•BUILDER DECLARATION Name , ;� z Fj.8 A-
1 hereby 3(r�m �hat 1 �m eaempt fmm the Contraetnr's Addrosa ��• • • • •5 .
License Law tnr the fotlowing reeson (Section.7031.5,Busi• City Tel.No. '
ness snd Profecsions Code): � •4 9 Q 5 0 :
� 1,as owner of the property,am ezctusively contracting � '
with ticenud contractors to construcl the proJect • •4 9 Q 5 0��
(Seclion 7044,Business and Professions Code).
01,27-84
CONSTRUCTION LENDING AGENCY
1 hereby affirm [het ihere is a construction IendinQ a�ency �
fot the performance of the work tor which this permit is _ �
issaed(Sec.3097,Civ.C.).
Lender's Name .
Lender's Address '
1 certity t have ead this applicalion and state that the
above infor n is c rect I agroe to comp�y with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinance tate 1 regulating Plumbing, and hereby
authoriz re entati s f thi nty to enter upon the
above� nt' prop ty ' spect�on purposes.
g ture f Per �tt� Date � ' �
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