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HomeMy WebLinkAbout1255A (6) WORKERS'COMPENSATION�DECLARATIDN �� � APPLICATION FVR� PLUlV\�ING PERMIT �� � y he eby affirm that I have a ce r f�cq}e of consen lo self,n- 76�6 ADPW 4!87 � �� sure ora certificate of Workers Compensat on I�surance,or a� CE ep(Rev aie6'�- � �� � � .� � -� certified copy thereof(Sec 3800 Lab.C) � � . � . . . . ` '29-54-10 .,�riployees Benifits COUNTY OF LOS ANGELES DEP7.OF PUBLIC WORKS . Policy�No. -Compa . � .� . . . . . . . . . . ".�� Cert f ed PY s hereby f rnished ..-.' .� �.... �' � �. � .." ..��.... '�...� � �� . � DI'JG���: ' .�. . � ... - BUIL . .... . ,. .. .. � ,, FOR APPLICANT TO I.L IY('PRIN'CR TYPE) qDDRE55 2 26�I5 Lazy Meadow Dr.�� � Cerhfied copy is filed w th the�covnty Idi n ecnon `� . � � department. ' NUM6ER F�XTURE 6R ITEN� @ FEE LOCNLIT� - � : //� Diamond Bar � f3,ate 7-1—�� APPl�icant ` .. W . WAT'eRCLO5E7!iOILET: .......... � NEAREST.....� . . . . . . .. . �� CERTIFICATEbFEXEMPT� N�F OM�WORKERS' BATHTUB� CR0555i. ; -��.� "'��� COMPENSA71;, I �RANCE �� . . SHDVJER� I �W�vERG'OU11tYy Estates ASSOC...�. .. � ; .., . . . . . . .. .. � .�,(This section�need nof be com- ed�if ffie:work involved hy - rnai� �� � � - - ���-fha permif Is for ane hundred do.11ors�(5100)or.less.) IAVATORY� . ADDRESS 22�615 La:zy �Mead.ow -Dr. l cernfy thot in'tFe performance of�i`nework for wli,ich thi,s per- . SINK ,�'.�iV D 1 clI(LOY1C1 $a�Y � iEC�ti :��mlt is issoed,I shall not employ ony person �n or.y manner so . � �61—41 14 .asYo become�sub�ect to�he Workers'Compensaiion Lows.�' � DISHWASHER. � � ` coNTRna�ohn A. Martin Htg. & A/ 'oore aPp��a�� aoTHeswnsHea �coaess442 W: Bonita Ave. �NOTICE TO APPL�CANT:If,�afier maki�ng this Certificate of Ex-� � SWIMM:NG FOOL RECEPTOR iempton,yoo�should'oecomesu6�edfotheWorkers'Compen- ' aivSan Dimas � re�.Ncb99-2901 . �sat on provisiorss of�the Labor Code,you musY forthw Ih<omp- - IAVdN SPRINKLER SvSTEM . � . � 1y ifh svch pro isions�or ihis permir sholl be deemed�revok-. , � TATE � LIC.-���� ;�d . . . , ,. � WATER HEATER '� c.CENSE N0.3 1 5.1 Q 3 CLASS C 2� - LICEN5ED�CONYRA�TURS�DECL1(12A�ION � ��� � D'�STRIQ NO. PROCESSED B:' - ��6e�eby afficm thar I om licensed under pro�isiond of Chapter � GAS SvSTEM l Ou71E75 J.,�� .O , ,(commencing w rh Sectio 7000)o4b s on 3 of�ne 6us ness- OU7lET50VER� - ' "" ��',,,���,ppp , � _ . hd P fessions Code,and my I cense s n F II force and ef- 5 PER$YSiEM � , - �'' F;NAL -T, ..9y�/ VALIDA ION a .,��t .. . � . . _ .. � �, �ATE � ��V� . . . . . ... � ' O ':ense Numbe��5�16-3�Lic Closs C2�..... . . . : U � �--� 7 31-90 gYNa` O nir qs � Daie... . . .. : . _... F �•� I exemptunder.$ec.. � .. , .. �� � �� W a B.BP C.for fhis reason . � P�tlf1�Ch@Ck fC@ . P•��-� / �� � Z ' ' Date . _ pLUMBING PERMIT ISSUING FEE,$ ��: � Signature � � �� . � . � TOTAL FEE z 1 G 5,:J N '. � ��� �SINGIE�FAMILY .�.,� ..- . . �Plon c �� - 'cant, .. ... ..... . ......... ...... �� . � � - HOME OWNER-Bl11LDER��DECLARATION -� � � �- '� � � � - -�by affirm thai I�om�exemp'�from the Contrqcror's L tense � Name - � � � � U��'�'� � 'or the follow ng reason (Section 7031.5, Business and . , ... -� � Sions.Code): . .. . . ... . . Address - - . . � � ; ; ��^1; .. .. . � . . . .. .._ . .. .. ..__,,.._...'_.... ,.��.. as�owner of the propeny, will do the work and�ihe �'�Y� Tel No. ��,`� `�� ruciure s not Injended ar affered for sole(Section7044, � . � � � � � - � � � - - is�ness�andPiofessionsCode)�.� �- � � - � �S � �. - - � , .�CONS7RUCTION CENDING AGENCY._` ' ._.�_.,,, � �- � � ' � � � �- � . . .....,. . _.... _. . . . ...... . .... . ..,�.. ,... . .. .... .. . ..,.. ......, ._.. ... . offirm that ihere.is a constructioq lend ng agency for ���� � � , � �� i�oim.anee of:fhe work.foi which tliis permir is issued � �� � ��� � � . ,'�� � �� � �, � � �� �. � , � .� , � _� � _ � � . .. ,. .,.....�. ... 77,Civ:C:).. . _ . . - _.�... . . . . � .. - .. .._ . . . �Name. � . . . , . � .:� ��... :- .:.�... - .: ..� . ._. .. . . . ,. .. . � ; '� � : � . � � . . �. ,.. . . ... . . , , . . . . . . . .. �Address. . � . � . .. .. . �'�. ,. � .. � ' . � �, . . .. . .. . . ..� ... ....., ..,.,....., .:.... ,....��.... ., .�..,._...., :,s�� ....:.. .. . . _. .. ... ... .... . ... .. .. . . ... . ..,,:... ... ....:... .. . . .�., . � �at I have read?h s appl Imt on and stpte that,the � �� � . � - xmqtwn s m[(ect I agree ro comply wilh oll County _ , � �.�s and S�ate.lgws.regulating Plumbin ,a d here6y � . re�ese atives of�this-Co 6' nter upor. the r�!ne prop"F r�n ion - � ose. �, f ' SEE REVERSE POR EXPLANATORY.LANGUAGE -� .� T Pe�miftee D te � . �i �.. . - . . . .. ��., � �' � '.. ' . � . ,. , . , s�...�:.._�.: ..� _ _'��m�' �`��"�'" --�' ����NSP�CToasa�or�s �WNERSUiLDERDECLARATICk..... APPROVAIS� DATE INSPEC70R'SSIGNATURE , ��_a,�_,�,.,_,_,„,�,.��p,e,�, . � � � " � UNDER SLAE WOflK �-. .,. . . . .., � h'�YBby 8lfkrtl th8t I df11-BXBIIIpQ f�Wf1 ihB�C011t(BCTOf S Rou�ri Pu;MaiNG ----- � �� � � . �� . - License Law tar the.following reason (Section 7031.5. Business and Protessrons Corle). Any r,ity or couniy �as aiPiNc _.� _ _ _ which requires a permit to consttuct, alten improye. cnsveNr demolish or rapair any structure,prior to iVs issuance. Hor wRrea HEntEe -- : ,. also requr�es the apptrcant ior such permft to N7e a slgned �� � �� � �- � �statement that he.r,'s licensed pursuanf to Phe provrsions PLUMBINCaFIXT�pES �� ' � - -� �' __.—_ _ �._��� - otiheContraCtor'sticense2awjChapter9{commenaing cHs res'r wiih Seciion 7000)of Drvision 3 ot the Business and Pro- unu�v co.won�!eo, , _- __,., __,_._. _. . tessions Cotle)ar Yiiaf he i&axempt thereirom 8nd the .. — - _ , . _ Dasrs for the a!legetl exemption.Any violation o�Section _.. ,...._ .,::....w.. 7A?i,5py anY aPAlicant ior a permit subjecis the appli- FINAL ... n e7 . . . . ' .......... . . . . . �Gnter on�`ron@ cao?to a civil penalry o!rrot more than.fiv,4 hunqred. . _ _ ..— . doJlars($500).. . .,.......... ��� ❑1.as awnar of the.�propae¢y wi+l da ttre rvark,and the 3NDUSTRIAL �� � �` � � - - � � WASTE APPROVAL�' ���"� ��" -- � � � . 8tII1CtUt8 IS flOt iIl'�8fld0fA Of OffBfBd fOf 3818. — _� ...... ..,.. ........ . . _ .... .. . .,..,....... .:...:......� .F...-..- ... ......._.... .....,...... ..........._ ........ ..�S2C..7044.SU$MBSS8�dP/OfBSSlOR$COde Tt78!b(7Tf8C- . . ._. ,.,.., ... ` - tor's Lrcertse Law does npt apply to an owner of property ' — _, ...,._. _. __.. _ . who 4uilds or impioves thereon.ano who does such work : _ ---. ___.... . himselt provided thaP such imArova.mants are nof intend-. . _.--. ... _ . . er1 or offered to:sale.!f,nowever, the building or im- :'. -. _.,......,_.Arovemeni!s sold wiihin orre Neai ot completion, the -- .,,.�.,., ,.,..: . , owner-tiuilde�will have ihe burden ot pioving that he d+d not bulld or improye for the purpase ot sale.) , , �-- _ ._.. _.,__ !a�ii exempt undeT S�ec: . . ._ _ .........; ---- �....,._. ._. . .. .. ....._.. . _.. ..�.w . .._.. _. .. _.,.,,..__.. _. . . _ B 8�P� for this reason --- '` , �.:�..,..:..._ , :.�;,— : Dat�s.. — --- �._�__,�:....._w.�._� OwneY _ ._,. r � ,� .. . 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