HomeMy WebLinkAboutNo Permit Number ;
WORKERS'COMPENSATION�ECLARATION A nne �r A Tl�er� rivn ne o,r�n�aow e��nu�r
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� 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 ,
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