HomeMy WebLinkAbout1804A . � WORKERS'COMPENSA710NDECLARATION � - APPLICATION FOR PLUMBING PERMIT �
I hareby,afFirm thol I have a certificote of consent fo self �gj�gg�p �
insure,or a certificofe o�f{Wlorkers'Compensolion Insurance, CE 817(REV.8/88) - - - � - � � � �- - �-.
or o cerr{i����vOS��G7UO�(4�tTATIO�IDE COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ,
oty No/ Company LOt Za PLaII � '
Cerlified copy is he�eby furnished.
� � - � . FOR APPLIUNT TO FIIL IN PRINT OR TYPE) BUILqNG -
Cedified copy is filed with the tooMy building inspec- � o,00a�ss �24352�East Nan���Court��
ti0n depo��ment. . . . NUMBER FIXTUREOR ITEM � �E i�u.iry � Diamond�Bar � -
�Dote 9�8�57 � �AppliSonl Nem P1„mh;ng WATERCtOSET � NE,qREST Grand Avenue � �
� .CERTIGICATE OP EXEMPTION fROM WORKERS'. � BATH TUB . . . CRO55 ST. � � -
� - COMPENSATION INSURANCE - � SHOWER o`"'^iER , Bramalea� California, Inc. . �
: (ihis��cNon nNd aof b�complN�d if 1b�work imrolr�d by �t� . . .. . ..
th�p�rmit b!or on�hvndr�d dollnn(f100)or I�as.) � lAVnTORV ADDRE55 3].51��l�TUI �"
I certify ihat in�he performonce of the work fa which�Fis ,.
, permit is issued,I shall nol empioy any persvn in ony manner SINK . CITY TEL NO. �
so as to become subject l0 1he Workers'Compensation Lows. DISHWASHER � '
�°"rta^�T°R New Plumbin Contractors
� � eppiiwnl � - CIOTNES WASNER - '
r �CE TO APPLIUNT: If, aNer making ihis Certifitate of . ��� 2 - �� � '
taemption,.you should become subject to the Workers' SWIMMINGPpOIRECFPTpR .
Compenwiioa provisions of tbe Labor Code,�you m�at(orth- � LAWN SVRINKIER SVSTEM ��tt �`�NO� 937-3972
�wit6 comp�y wilh such provisions or �his permit sholl be STATE IIC.
deemed ievoked. ' � � WATER HEATER _ ����� 426109 cwss
� • IICENSEO CONTRACTORS�KIARATION ' � � DfSTRiCT NO. PROCESSEO BY
�I hereby�oNirm�hoi I am lite�sed or�er provisions of ChapM�9 � GAS SVSTfM oui�is �- . ,
�(commenting wi�h$eclion 70p0)of Division 3 of the Busioess puTLETS OVFR . � h a I
ond Professfona Cale,and my liteme is i�full forte aed eHxl. 5 PER SY57EM FDIA�L _//�/�� - VALIDATION V�,
license Numbei 426109 i;�.cio:, C36 ���
¢ ;
FINAI
comroc�or New Plumbing pO1e 9-8-87 ev �r� - v �
❑ W
I om ezempt under Sea p ,
..8.8P.C.fa th�s reoson y
Plan check fee , :"1 8 Q 4 A =
. . . ��e� PIUMBING PERMiT ISSUING FEE; . .�f' • ° • •j
SiflnoWro
TOTAL FEE I � � � ll.O O
. Plan check opplicaM - � >,j � ;'R c��
SINGLE FAMlLY �
} HOME OWNER•BUILDER DECIARATtON Name � � - � � �- - 0 n 1 7�v'7- -
-_..�Sereby affirm that I am exempt from�he Conhocior't Liceme � pddross -� - � � � - - �� �
law for the followirp rea�on(Settion 7031.5,Bwine�s and . .
� Professions CodeJ: Ci1y Tel.No. � .
❑ I,os owner of the properry,.will do the wwk ond the . �
.ahucturo is nm i�teoded or offered for wle(Secfion ---� -- ��- � � . - �- � � � � . � � � �
7044,Buii�ess a�d Vrofeuione Code). - ��
CONSTRUCTION I.fN01NG AGENCY � �� � - - - � " � - � �- ' '�� '- '
I hereby affirm that there if u conahuttion leodinp ogency for � � � � '
the performance of ihe work for which Ihis permit is iraued - - - - - �- - � . " - -�� � �
ISec.3097.Civ.C.). . . .
Lenderb Nome � � -
lender's Addrees � � . �. . . .. . � .
I certify thal�iwve read�hia upplicotion and s�ate thot the . .— . . . . .. � . . . ► .- - . .. . .. -.. .
above informotion is corrxt.I agree to comply wilh all County �
ordinances and State�ows regulating Plumbinq,and hereby . _ , � � . .. _ . . . . . _ . . . . _ . .
ou�hori:e represemotives of tfiis Covnty 10 en�ef upon the � � . _
o e- lioned properly for inspacfion purp ses.� - � �
SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ure of Permittee Du�e . . . . . - . . . . . .. . . . .
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