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HomeMy WebLinkAbout1804A (10) . � 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��cflon nNd aof b�complNod if 1b�work imelr�d by �ti 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 - �� � ' taemp�ion,.you should bCcome subject to ihe WorkCrs' SWIMMINGPpOIRECEPTpR . 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�he followinq rea�on(Section 7031.5,Bwine�t 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�he work for which Ihis permit is is�ued - - - - - �- - � . " - -�� � � 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 . . . . . - . . . . . .. . . . . .�_ - - -. _ - - ------�. . . . , : . . . t I �" C Gl �' 2 � � n G N� z N C O N N CO O � T N ^ + .( "� m S � � � A , . _ ,- ' . ' � In _+ ♦'� " " - � � � ._V _'� Nt- . • . � : _ . Z.,....'' ,�.a. � _-�.' . ,f� � �' ,., T r„ -• G� C W m, __'.. _. . . � � � �� o� I� ` y � S a, _ , . • ' I �r; y, t` � o � m � F; o o . ` i �� r � �., ' � � � , . . .. -, . ' , "._ i lYJ ' �- �_ II N I ' Jc . . ' ' ,� l i �J f�/v � r 1� �. 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