HomeMy WebLinkAbout1748A (445) 3 �
WORKERS'CpMPENSATIONDECLARATION p�pp�.t���'!O!� �OR P!!!1l�lBlR�G PERlVIlT
l hereby affirm that I have a certi4icate of consenF�o self 76AG6�A ��
insure,or a certificafe of Workers'Compenzation In:urance, CF 817(REV.10/BI) -
� or a tertified copy thereof(Sec.3800,Lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
a�YrPf:�diL�.W��^Pa�Y�YP�Art TTl[�PiI11'1],ty � .
; Cer4ified copy iz here6y fumished.
� FOR APPLICANT TO FILI IN(PRINT OR TYPE) BUIL�ING �
� Certified copy is filed wifh the caunly build' g inspeo- ADDRE55 d` ��
� � NUM6ER FIXTUREOitITEM � IOCAIITY Diamond Bar
fion deporfinent. � FEE
pote ���Appli4ant WATER CLOSET J � NEAREST
�a _ �RosssT. 60/Philli s Ranch
CERT4FICATE OF EXEMPTION FROM WORKERS' B.4Ttf 7U8 .
COMPENSAFION VNSURANCE SHOWER �wNER S011tll CO
(TAk sactioe naad not ba cempEsE�d'ef th�work Mrolvod 6y MAit
f6�p�rmi!i�for ona kvndrod dollars(SI00�or lass.) kAVATORY AD�RESS -
!cartify that in the performance of the work for which this OV1123 —
permit is issued,1 shall not employ ony perso�in uny manner S�� ��n' � TEt .
so aa to become subject lo�he Workers'Compensofion Laws. p1$F{WASHER
l � -- CANTRACTOR • • • � ingf C.
oa�e epplicam CLOTHES WASHER ` A�� 12785 Magnol2a Ave.
�'"�TICE TO APPLICANL• If, ofter making this Certifimte of . ,
mpfion, you should bemme subjact to !he Workers' Sw������RECEPTOIt
�ompenwtion provisions of ihe Labor Code,you musf forth- CI7Y Riverside 92503Te�No.371-50Qf1
LAWN SPRINKLEF SVSTEM
ith compky with such provis;ons or this permit shatl 6e ' SiAiE ��.
deemedrevoked. WATFRHEATER ����No. 336428 c�Au C-36
IICENSED COPITRACTQRS DECIARATION DISTRICT NO. � .�PRO�SEO 8Y
I hereby affirm thot I om licensed undar prov�sions of Chapter 9 �SYST6w OUi�ETS r �/
�commencing with Section 70G0j of Division 3 of the Business � OUTLETSOVER l ?' i
and Protessions Code,dnd my 4icense is in full force ard effect. 5 PEB SYSTEM F��� ' d !
license Number��._ttc Ciass�� OATE /j� J f� Y IDATION u �
FINAL �
Comracror �CR P LV1IIk71ri�note 6/19/85 sv �J���� V
� �u
I am exempt under Sec. y
y
8.&P.C.for this reoson - � �
Plan check fee �. —
Date: .. .. p�u/Y}giNG PERMR ISSUING FEE$. .. . . .. . . _ -. . - .. t
lH ###
.Signoture G,�y� �� ��7 Q,�A �
TQTAL FEE ��
�ri��}�
P�an check opplicant
SINGL£FAMILY � •�8 a�J 0
HOME OWNER-BUILDER DECLARATION Name L'+�
i ereby affirm that I am exempt from the Contracror's license _ , . .��!.�.�5 Q=
Rdd�essl27g5�.Ma nolia Ave. "
.�w�for the follow'rng reason (Secfion 7031.5,Business and ' � �
Professions fode:
) cuy re�.r�o. 0 7.2 9 y 8 5
❑ i,as owner of the property,will do the work and the 1VeT81 e — 000
structure is not intended or offered for wle (Section � . � ►
7044,Business and Professions Codej. � -
CONSTRUCTION LEN�ING AGENCY
I hereby affirm ihat fhere is a conshuction lending ogency for '
the performance of the work for which this permi�is issued ,
(Sec 3097,Clv.C.).
lender i Name
Lender's Address
I tertify fhot I have read this opplicati�n and state Ihot the �
obove information is correct.I ogree to comply with all County
ordinances and State laws regulating Pl�mbing,and hereby
authorize representatives of this Counfy fo enter�pan the
obove-menlioned prop y for inspecti purposes.
� SEE REYERSE F�R EXPLANATORY LANGUAGE
R.c.x. $y:f'���vRS �
Signature of Permittee Do�e � �
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