HomeMy WebLinkAbout1764A WORKERS'COMPENSAiION DECLARAiION ��P!l���lQRI ��� �C��B�OC� �G�YYi�i � � I
I hereby offirm ihat I have a car�Ffimte of mnsent�o self �yqyb�p / �
insure,or a certificote of Workers'Compe�safion Insurance, CE 8l7�REV.10/81) � �
o.a certcf�ed copy theieof(Sec.3800,Lab.C.� COUNTY OF LOS ANGELES BUILOING AND SAfETY
ac�,b��ompanyFramnnt Tntlamnit3T � �n
Certified copy is here6y furnished. T�
� FOR APVlIG4NT T6 FILL IN(PRINT OR TYPE} BUIIDING ��q��
Certified[opy is filed with ihe county 6uilding inspe- ADDRESS � /�,Yy
liondeporfinenl. . NUMBER FIXTUREORI7EM � F� �p�p��7� Diamond. Bar
Qa�e G��Appli4ont * WATERCLOSET fiC NEAREST
- CERTIFICATE OF EJ(EMVTlON FROM WORKERS' BA7ffiU8 _., �aossst. 60/Phillips Ranch
COMPENSATIQPF tN5t1RANCE SHQWEa - OWNER South Countr CO�
(Thk wetian noad not ha compkated tf the work�nrcivad by huit
1ho parmR k�for ona huedred dollar�(SI00}pr Iosi.) wVAiORY � � --
!ceAify thnt in the performance of the work fw which�bis .4DORE55
permit is issued,L shnif not employ any person in any manner SiNK CtTV TEL.NO
w os to become subject to ihe Workers'Compensofian Laws. / DISHWASHER - �.. •
- CONTRACTOR R,C.:R. Pl�tmmbin INc.
Dafe Appli[ant CLOTHES WASHER �^ App��
r'�1TICE TO APPLICANT: If, after moking this Certificate of 12 85 Ma olia A
� mption, you should become subjed fo the Workers' SWIMMINGPOQIRECEVFOR .
".mpensaFion provisions of the tabor Code,you must forth- ��N T�.�.
with com I with wth rovisions or.thiz ermlt shall 6e ��✓NSPRINKLERSYS7EM � � �
P Y P P STATE � tK.
deemedrevoked. � YVATERHEAiER ����Ho. 336428 ��,u C-36
L(CENSED CONTRACTORS�ECLARATION D�STRt�T NO. . pR�55Ft1 BY �. 1
_. t herEby affirm?hat I am licensed under prpv�sians of Chapter 4 _ � Gn5 SVSTEM �� OUTlFTS � � ��._ _ _ �� _ _ _ . _ _� _ � ;
(Commencing with Seclion 700p)of Division 3 of the Business OUTL€TSOYER � �
and Professions Code,and my license ia in full.farce and eNect. 5 PER SvSTeh� � FINAL � � ' - � �
_ .. _ .._ ._.. . .. OATE. _/iZ f.�j�S�✓'� Y LlDATtON ... v
Cicense Number�tic.Cioss� - ....- - .- . - .. . . . - � - . . � i
. . ._ . .. . . .
_, ._____.._ _.._. .__ _.___ . _ _ �_ ._ . _ .
,
coonono� RCIZ. P luiubing oa�e 6/19/85 sY A�f)?/�' v �
❑ � �' 1
I am exempt vnder Sec � ,
B.BP.C.fw+h�e reoson - - - - - -
Plon check,fee " �
Oate� PLU.4lNNG PERMIT 755lEtNG FEE S . .. .f(J �t; � - . - .. � � �_f Q 4�A �..
. .. SignaturA � . ... .. .. . _. ., , �.. .. .. _ _. . . , ...._... _. ,.,._,_ ,.._ ... _ _ .
TOTAI FEE +�[_�� , �� � �'�
.. _ .... .. _... . �
. ly
� Plon check appliconf � • �7 b 5 G �
� SINGLE FAMILY I�(�`, INC. • � •l�5 d� �
HOME OWNER-BUILDER DECLARATION Name
�eby affirm that I am exempf from ihe Conhacror's License O la V�. 7 �µ �
� i for the foflowing reason(Section 7031.5, eusinass ond � A�eu - � ' Q 2. �,,,
�Professions Code�: � Gty Tel.N �
❑ �,as owner of rhe ro er •����� �
p p ty,wii�do the work and the . . � �
struct�re is not intended or offered for sale (Section
7044,Business ond Profeuions Code). � . . -
CONSTRUCTION LENDIIVG AGENCY
I hereby affirm thot there is o construction fending agency for . �
ihe perfarmance of Ihe work for which this permit is issued
(Set.3097,Civ.C.).
tender's Name . �
tender's Address
I certify�hat I hove read this applimtion and state iha�the �
obove informarion is correct.1 agree to comply wi�h all County
ordinances and S�ate laws regulating Plumbing,and hereby
avthorize represen�atives of this Coun�y to enter upon the
above-menrioned pr erty for ins ciion purposes. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Fermitlee Da�e i
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