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HomeMy WebLinkAbout1811A (10) . � WORKERS'COMPENSATIONDECIARATION APPUCATION FOR PLUMBING PERMIT � � � � I hareby,affirm rha�1 have a crtificate vf consant ro self 78A887A � � � insure,or o cerlifim�e of Workers'Compensafion Insuronce, �CE 817(REK 8l88)- - �- � . . . . . . � or a certified copy lhereof�Set.3800,Lab.C.) . � ' � �- - ' aoucy No.73WC0050�a��� Nationwide COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS � Cari�fied copy is hereby fumishad. Lot 2�� Plaxi 24 . . - FOR AiVLIUNT TO FILL W(PRINT ORTYVE) 6UILDING - � � �[ Cenified copy is filed with the counry building IMpec- nDDRE55 24366-�East Nan C•Ot1Tt `7(" lion department. NUMBER fIMURE OR ITEM Q FEE �ie 9/B/87 p�pli4ant New Plumbinz w�hettoser 1OCA"TM Diamond Bar NEAREST , . CERTIFICATE OP EXEMPTION FROM WORKERS'.� . aarH rue . . . Ca063 SL � � � � � - COMPENSATION INSURANCE. � OWNER�. � ���� (Thi�rMlon oNd nof b�compbt�d if M�work inwlr�d by SNO�R ea Calif ornia lnc. � � ' ". 1h�permit b!or on�hundnd dollon(5100)or I�ff.) tAVATORY A��a�ss - 3151 Ai.xway'Ave:��.$te N -� , .I ceriify that in rhe performonce of the wo�k for which this _ � ` _ pe�mit is issued,I shoq nol employ nny ppqon in any mnnner S�NK , Cltt�� OpSCfl Mesa ��'�' 85�-1��1. — so as to become sublad to the Workers'Compemalion Lows. � DISHWASHER � � � � �°Nrann°R m ontractors � ' Applicanl -. ClO7HE5 WASHER . . ADDRESS � . jICE TO APPIICANT: If, oAer making this Certificaie o( � � � �- ��"[.emplion, you should become'�u6jec� to the Workers SWIAhMING POOt RECEviOR , Compenw��on provisions of the labor Code,you mvsi fohh- ��TM Anaheim T��•�� 937-3972 with mmply with such-pro�isions or fhis pe�mit sholl be �`WNSPRINKLERSYSTEM , ` deemed revoked. � - � � � ' � - WAiER HEAtER i�Ns�No.- 426109 `c nss C36 _ � - - LICENSED CONTRACTORS DKLARATION ' DISTR�CT NO. iROCE55ED BY �1 heteby affirm thof I am IicenSed undm provisionz aF Chapler 9 GAS SYSTEM � OUTlETS �� �commenting wi�h Se[lion 7000)of Division 3 of Ihe Business OUTlET50VER O y ond Profeu�ons Code,ond my licenae is in full force and eHect. 5 PER SrSTFnn � � DA EL 3/,z�f/�� VALIDATION �- license Num6er 426109 i�� ��� C36 ¢ co�r,o�ro�ew Plumbing pa�e 9-8-87 BY A� ��— � ' ❑ I om eaemp�vnder Sea . . . - a �� � .... 8.8P.C.for th�s reason � � "� ��.1 A x ' Plan check fee , i;o , • •5 . ��e� PLUMBING PERMIT ISSUING FEE_ S�gnat�re I � � 0 8�� TOTAI FEE � . . . . . . - � � • o � �(i�Q:�- . Pion check opplicanl � - SINGIE fAMILY ��� 7_8 7 HOME OWNER•BUILDER DECIARATION Name -._ereby affirm that I am eaempt from ihe Contractor i Liceaae qddrea � - � � law for Ihe following reeaon(Sacfion 7031.5,Busineas and � �- � � �' � � . Professions Code: � � � ❑ � Ciy Tel.No. 1,aa owner of fhe property,will do ihe work cnd the . , struclwe is not INended w offered fw tole(Settion . . . � . , . . . . _ 7W1,Business and Wofxslons Code�. � - - . CONSTRUCTION LENDING AGENCY �� . - � � �- � �� � � � - -� - -� � � I hereby affirm that there is a tonshoc�ion lending agency fo� � - � rhe pe�fo�mante of fhe work for which ihis permit is issued � ... '.... . . - . . - . �-. . .. . . . . . . . -. . . . (Sec.3097.Civ.C�. � . . . . Lender's Nome . ._. .. . . . . . . . . . ... . . . . . . . . ... Lender i Addross � � � � � � I cerfify thot I have reod this opplicuuon ond sto�e that rhe . . . . . - - , . _ . __. . . . obove infamo�ion is corrxt.I aryee to comply with all Co�ny , ordinonces ond Siote laws regutoting Plumbing,ond hereby outho ze reprosenfatives of this County fo enter upon the � � � - - � � � � � ' aba �n lioned property for inspeclion purpo s. � . � . � . SEE REVERSE fOR EXPLANATORV IANGUAGE i $iqnalure of Permittee Date _. . _. . . .. . . . . . . . . . . . .. . . � . ,. � ` ... ... . . - . . . . . �_Z -.. C Gl .'�- = Gl G1 A C .. Z = cDn C � cDn � C� c� N" D my I j m p � < o G1 � . . � .__.._�--._.i y.,� �.�., � � � y. z T N ' _ I .� , ' `_ • �_.. .. - ' � +s � � � --� _ � $ 4� I 'c t � „ a G� � �'• O 1 � y r o, < p i � r j � <: 1 yl I - � m �� � N D • � � � . ' : '- i: I i I � � i�, i -- O �^ x' � � � - - i_ ;`: � � ' � � � . `^ ; f i,- �'' i � ' _- _ ' � � �- � i_ � � _.� ', .v �- i.. 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