HomeMy WebLinkAbout4544AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 7&A667A
insure, ar a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81)
or a certified copy (hereof (Sec. 3800, Lob. C.)
Policy No. 5075288 Company Farmers 42568
Pol
Certified copy is hereby furnished.
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec-
tion deportment.
Date 12/18/86 Applicant PRO Plumhing
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed It the work Involved by
the permit is for one hundred dollars ($100) or loss.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dale Applicant
h'^CE TO APPLICANT: If, after making this Cerlificate of
ption, you should become subject to the Workers'
t__. pensotion provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereb affirm that I am licensed under rovisions of Cho ler 9
no;acssFORAPPLICANTTOFILLIN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM (
3 WATER CLOSET
3 BATHTUB
SHOWER
LAVATORY
1 SINK
DISHWASHER
1 CLOTHESWASHER
AADDDRESS
SWIMMING POOL RECEPTOR
I DD
LAWN SPRINKLER SYSTEM
1 WATER HEATER
1 GAS SYSTEM 5 OUTLETSYPP
commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM
License Number 443774 Lic. Class C-36
Contractor PRO Plumbing Dole 12/18/86
1 am exempt under Sec.
B.BP.C. for this reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE $
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNIR-BUILDER DECLARATION
rbyaffirm that I am exempt from the Contractor's License
Tor the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Cade).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 9097, Civ. C.).
Lenders Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize repreitenta Ives of this County to enter upon the
above-ment;oned r erty for inspection purpose .
c
ignature of PermSrree Date
r
ck applicant
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10.
l!_d,Ctpi
5
1.1G0..5 0
1223-86
of
OU
0HU
Q.' N
z
no;acss 24445 E. Thunder Trail
FEE Diamond Bar
i 00
LOCALITY
NEARESTCROSSST.
OWNER Bramalea Calif.
00 AADDDRESS 3151 Airway Ave.
I DD CITY Costa Mesa TEL. NO.
CONTRACTOR PRO Plumbinq
nn ADDRESS
4418 E- ChA.MRA
CITY Orange TEL. NO630-8441
STATE LIC.
DO LICENSE NO. 443774 CLASS r-3,5
DO
DISTRICT NO. PROCESSED BY
0 q
FINAL VALIDATION
DATE 1..T—s-7
FINBY AL
7 O _
SEE REVERSE FOR EXPLANATORY LANGUAGE
10.
l!_d,Ctpi
5
1.1G0..5 0
1223-86
of
OU
0HU
Q.' N
z
0
C: e;= o e c
C. 9 R E
g 2 R
JQ Q e
a I i t;z;E
e
a; acLt.Q4 o EJ[%[Jif§t§;ƒ
tzt2 -A. - .
RE}ek a(QQ\E{C_=_C) gym%
R;SO
R°[\f£kR\m 3]>7B
z2= I>-^=o, _ e e §.Ege°°r-[I{
EES-
E0rL
z -
m[R§§/ aCL a ( 337!2 n(E 0
0sD./
I Q°{ 2o\) _-
On
J § axZ-
S°§}
2;
c
k®
6.
o
i&
ia.
2:&:» &
EM\2
E]®@ / ]\EE:-®&§e)
iKf&9&273)±«z
j
W