HomeMy WebLinkAbout1774A . WORKERS'COMPENSATION DECLARATION APPlIC�►TION FOR PEUMBING PERIUIIT � '
I hereby affitm Ihat I have a certifimte of consent to self 76pyyjq , �
insure,or a certifrwte of Workers'Compensation Insurance, CE 817(R€v.i0/Bi) �
or a certified copy ihereaf(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �� �
P❑oHcy�.��a�ompany Pt'mm�nt Tnrlamnit
Certified copy is here6y furnished. y � `J 3e' �
� FOR APGLICANT TQ Flll IN(PRINT OR TYPE) BUIIDING �
Cerlified mpy is filed witf�Ihe county buil�ing inspeo- ADORE55
- fion deparfinenf. / NUMBER FIXTUREORITEM � �� �p[q��7y piamond Bar �
� WATER CLOSEi l
��e G`�TA�'��ant ao�SST. 60/Philli s Ranch �
CERTtFICATE OF ExEMPt10N FROM WORKERS' sntH tUe �. — j
• COMPENSAFION INSURANCE SHOwER OwNER South Countr COT i
(Thls saetion nwd not 6a tompbfad if Yha work inrolved by .
elro porm{t is For ono hundrod de{lers(Sl�j er less.) � LqVATORv � DDRE55 `
I cer�ify Iha1 in�he per4ormance of the work for which this �
permit is issued,I shall not employ ony person in any manner f SWK � CITY � TEi, `#
so as to become subject to ihe Worke�s'Compensption Laws. DISHWASHER 1
E°"TR^�T°RR.C.R. Plumbin INc. �
Date Applicanr / CLOTHE$WASHER .� �
AD�RESS
"�TICE TO APPLIGINT: If, after making this Certificate of 1� M I101�
SWIMMING POOt RKEP70R
( ^PI�Sn, ybu 3NWkF bbcOrt�a Sbb�6'2F tb iHe WwkBrS' � .Cy�r_. __ �El:NO.� • ��
���mpensotion provrsions of t6e[66or Code,�yai musl forth-�' � � �qy,�NSPRINKLERSVSTEM �
with compfy wish such provisiona or Ihis permit shall be SFATE LK. !
deemedrevoked. WA7ERHEAiER ����Ho. 336428 �� C-36
LICENSED CONTRACTORS DECLARATION DISiRICE NO. PROCESSEO BY
. !here6y afEirm tfxit 1 om bcensed under provivons of Chapter 4 GAS SVSIEM OUTLETS �
(commencing with Sedion 7000)of Division 3 of the Businoss ouTteiSOvea � � �
and Rofessions Code,ond my license is in fu�l 4orce and effed. 5 PER SYSTEM FlNAI,
onre li�l��d 5� YAIIDATION fl �
License Number��.g.��lic.Class�_ � �
FINAL
cofli.a�ro. RCR Plumbine�te6jl9f 85 av �Z}� � ,:
� �, �
I am exempf under Sec. a :
uY ;
B.dRC.£or thfs reoson T �
Plan check tee � e
Dote: p{UMBMG PERMIF ISSUING FEE E `1�7�l F� .
Signature �d � c
• TOTAL FEE *� � •�! �"
'7(�.5�
. - Plon check appticant t • • f�.�i Q
� � f� `� . . s : �i'65L;v
,
� .v for lho-ioflowin seasan Fon 7�34.5,Business and-�.: �.ii.:_.�............. .........s.__�._c�;,_.:.:.,.--'.'—_,�......:..
H M WN - UI L I ame • v •
'� are affirm that9 am�exem t from�he Cnmmctor's Licenae � . (�
� . . .. ...,�,,1
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Professions Code): City Tel.N
❑ I,as owner of the properiy,will do the work ond the ;
siructure is not intanded or offered for sale (Section j
7044,Business and Protessions Code). � � i
CONSTRUCTION LENDING AGENCY
1 hereby affirm thof�here is a canstruUion lending agenty for '
the performonce ot the work for which this permit is issued �
(Sea 3097,Civ.C.). � }
i
lender's Name €
Lender's Address �
I ceriify thaf I have read this applimtion and state that the a
a6ova informaiion is corred.I ogree to comply with oll County � �
ordinances and S�ate laws regulating Plumbing,and hereby
outhoriie representotives of ihfs County to en�er upon �he . f
obove-meNioned pr rty for insp ction purposes. �
p SEE REVERSE FOR EXPLANATORY LANGUAGE
R.C:.R R Q.�t�� �
g 6 J 19.18� `
$ignoture of Perm�ttee Da1e E
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