HomeMy WebLinkAbout4544A (16)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have o certificate of consent to self
insure, ar a certificate of Workers' Compensation Insurance,
or a certified copy (hereof (Sec. 3800, Lob. C.)
Pallcy No. 5075288 company Farmers
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Dote 12/18/86 Applicant PRO Pl mLhing
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed If the work Involved by
be 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.
Date Applicant
PUCE TO APPLICANT: If, after making this Certificate 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 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number 443774 Lic. Class C-36
Contractor PRO Plumbing Date 12/18/86
I am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
tbyaffirm that I am exempt from the Contractor's License
nor 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).
CONSTRUCTIONLENDING 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 laws regulating Plumbing, and hereby
authorize repreitenta ives of This County to enter upon the
above-ment;oned r erty for inspection purpose .
c
ignature et PermSnee Date
APPLICATION FOR PLUMBING PERMIT
76A667A
CE 817 (REV. 10/81)
Plon check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Nome
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10.
11 _
5
1.1G0. 0
1223-s6
COUNTY OF LOS ANGELES BUILDING AND SAFETY
4'
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDINGADDRESS 24445 E. Thunder Trail
NUMBER FIXTURE OR ITEM( FEE Diamond Bar
3 WATER CLOSET 18 00
LOCALITY
NEAREST
3 BATHTUB 1
CROSS ST.
OWNER Bramalea Calif. SHOWER
LAVATORY 24 OO AADDDIRESS 3151 AirwayAve.
1 SINK 6 00 CITY Costa Mesa TEL. NO.
DISHWASHER
CONTRACTOR PRO Plumhinq
1 CLOTHES WASHER nn ADDRESS
SWIMMING POOL RECEPTOR 4418 E- Chapman
CITY Orange TEL. NO. 630-8441LAWNSPRINKLERSYSTEM
STATE LIC.
1 WATER HEATER 6 00 LICENSE NO443774 CLASS —
1 GAS 5
DISTRICT NO. PROCESSED BY.
SYSTEM - OUTLETS 6 QQ O
OUTLETS OVER
5 PER SYSTEM FINAL VALIDATION
DATE ffFIN
BY
AL
Plon check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Nome
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10.
11 _
5
1.1G0. 0
1223-s6
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