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HomeMy WebLinkAboutNo Permit Number ; WORKERS'COMPENSATION�ECLARATION A nne �r A Tl�er� rivn ne o,r�n�aow e��nu�r � .................. -"--- -- - --- ---- -- - -' --'- -- -- -- ,-, � I hereby,affirm tha!I have a certifimie of consent to self in jbAbhiA r'°9'"' �1r 1 L14P'�1�V 1\ rV R f 6iAlY1�i1 V V �GR�YI�1 C� i sure,or a cerfificate of Workers'Campensptior�insurance,ar o CF&I/�,REV.8/A67 � certlfied copY thereof(Sec.380Q Lab.C.1 �_) 73WC00504�70004 Nation�aide COUNTY OF L,OS ANGELES DEPT.AF PUBLIC WORKS Poi��y No. _ omP��y__.._.___ Lot 27 Plan 25 Tra.ct 425 8- � Cerfified topy is nere6y furnished. � �ou nvi�ucAnr*e rui m��uiN o�t rvae '�'"N6 $90 S. Le land Drive � Certified copy is fi!ed with ihe county building inspection -- � - �A�DRF55 _ }� NUMBER _ _ FIXTURE ON ITEM _ _ ��LIT depariment. @ iEE ' 9-1-89 New Plumbin wa�eeuosEr;ror�n '� • ' � Diamond Bar oma nPoi��onr__ € ...� —_.._..._....-- ----`_�a_ � ��.ners Grand Avenue � '�� sarH rue I �::RO55 S! CERTIFICATF OF EXEMPTION FROM'JJORKERS' .:`� -- i } COMPENSATION INSURANCE ' sh'oti�eN I , Uwuea - $Tdlil31e8 Limited : (This section need not be completed if the work involved by --- - ' �� ,��q�i � � � � ,. I # the permit Is for one hundred doilars(5100)or less.) �_4vnT0�¢v ti_ ' r I qooue5s 3151 k�7-YW3y ES.V2.� Su1t0 N ---- --------- �' —'— 5 i certlfy ihot m ihe performonce of the work for which}his per- - --.--- �-; - mit is issued,I shall nr,t einploy any person�n ony manner so � 1I_SiNK f J� UIY COSt3 MeSB TEI NO85�-l��l `, as to 6ecome subject to the Workers'Compensahon Laws. �D�S�iwnSFiea TA , �nTFnCr�R N ;� PP y __ � -�— �- dr'" ; ;` ew Plumbing Contractors Inc ; Dnte. A licant I C�Ufi{�;WASHER ;, . -.___-_- _ _ . _ . _ ��"D°�ts', 2141 5. Dupont Drive : ?;,, V�o�l;1 � -___S�N NM1SP.NK�SYSi''NTOR i . _. JOiIC`e TO Hr'PJCbatil Ir a`ter moK�n mis i.erificate or Ex- � I ....�� �� � of ihe L.����suh.^t tc�I�e Workers'Com�en- . . .__...... �,_ i y ed.p Psu�h^� .:,, ...r Code`you must fortiiwdh c mp- � _-_ � � �V_ AI18�12171_ 92806 :. � � .n�co I . sat on rovawns �bo I _ z i�,,,��h _ r o.,<ions c,,ti s^� :!sh,,:l he aeereC rsvok- -_.__ ._ � � r5'aT� - � - -- ; � ,acT��HF<,iFe i J_ ; �sr�.�� 4261Q9 � C-36 IC�tiSeD COIvTRq.,iURS DECLARNTION - � I 5 C �� v ' h r.by aff rm thot I am licersed under provisions of Chupter �_ ����V�T�M �j "��"TS � I \ �� 4' .' 9,coinmencny w�h SeU nn 700U)ot Divis�on 3 0l the Business OC'LE i5 OVE4 � , �f� ,�I��' -���'�cJ � ❑nd Pro4ess!ors Code, � ::nd my licnnse is tn full force and ef �. 5 PER SrSrtnA +d7� ---.. � �— -- ----- _� � ��A;�` `�:��/. vnunarioN � _ _ � a 4ect. � � 426109 ' ���.aoss C-36 ---- _.....---- —��—, � �; license Number____ i .i._. .�_-_..____.__ FI'VAl �� � f Contractor New PZllIl1b1II� parp_8-j]_-$9 � - � -:� BY ;�s��'�w-" � • --- - --- - -- � ' � �-'--- --r------- ---�-�T-� -------- - G>. { I am exemps�nder Sec __ ;,V � _�_ CS. B.BRC.for;his renson - ..--�-' ► m ___._ + Plan check fee i r <.. - - � � — Date� PLUMBI_NG PERA4IT�SSU�NG FEF$ I ��'j',;j'7a , .._}.. . � L" , S�yna4ue ,�: � lOiFli"rEi �' �.' )�✓• ._�� t� '�': , _:. ; -. , 'r' . SINGLE FAMILY - rr 6 HOMF.i�'vvtiER-3UiL�[R��ECLARATION Pl�n cher.k u.p!i�_ant .; ' �: ; '_--- a ., � . . � I hereby nflrtm lhnl I�rn exen�ipi(rorn the Contrcxcfo�s Limnse Namr ., - . , , ., � Law for!he following renson (Sec.tion 7031.5, 8usiness and �-- �---��----�-----�.._. ._- � � f r ��1,f`�; R P�ofessions CodeJ: Address .... � � .. ..-- —�-- . . ...-- — m ,- � ? ri ., `�-; �j � I, os awnor of!he property will do ihe wnrk and the Crty TeL No. � i siruclure is nol in!ended or offered for sale(Section 7044, -----�-' �� -"— 'C��.��`7"'"�� a B�siness and Prnfessions Codel � i � CONSTRUQIUN IFNDING AGtNCY . � � I hereby aff�rm that there is a.ons!ruUion lending ayenty for � �he performance o+ihe tivork ior which thls permii is issued (Sec 3097,Civ_C-). � Lender's Name __ � Lender's Address � I certify�ha�I have read�his applimtion and state fhat ihc R nbove info��mafion is CO�recr.I ac�rec!o comply wiih all County � � ordinances and Stale!aws myulahnc�Plurnbing,and hereby � authoriz representotives af this Couniy to enter upon ihe ab enfiqned�erty for Insper.fion purposes. � �� � � �:/ , �,... , SEE REVERSE POR EXPLAFIATORY LANGUAGE �� Signarore of Permirtee Date , �c.�w-���ac.�::c�i;i_.-r.:,'-:�.-yr:r+^`�r.:rTc.::^,�:+:-j��C..�.. �r R i(�,D�' 'O,Z' � j�� ' A � ;_;GJ'�� i G'J'(lfi�CjO. 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