HomeMy WebLinkAbout1731A (447) WORKERS'COMPENSATION DECIARATION App!lCe4Tl�� FOR PL!!f!!!B!!�G !'ER!!!!!T I
I hereby affirm thot 1 have a certificate of consent to self ly�y�q
ins�re,or a certificate of Workers"Compensalion insurance, CE 617(REv.!olet) � /�
or a certified copy thereaf(Sec.3800,Lab.C.) (O
[��p 85321389 Fremont Indemli3ty COUNTY OE LOS ANGELES HUILDING AND SAPET
Policy'FYo.. Company �z8'
� Certified copy ia hereby furnished. . -�a.,e
FOR APPLICANT TO FIIL IN(PRINT OR NP€) BUILDING ; !B.
Certified copy is filed wirh the wumy building inspeo- AODRE55 • /[X,p)
tiondeparlmeM. NUMBER fIXTUREORITEM � �E �p�q�IN Diamond Bar
�oe 6/19/85 ,�,p,;4oA, RCR by wnTeRaoseT r�aResr
CERTIFICAiE OF EXEMPTION FROM WORKERS' �,z„ BA�H�1B �Ross sr: 60/Ehilli s Ranch
COMPENSATION INSURANCE ,� SHOWER OWNER South Countr C I
(Tbts sxtfon noad not b�tamplstod it fho work fnrolv�d by �i�
tht pe[mit fs far unQ h�adred dollar4(5100)or Iou.J � lqVATORY � ADDRESS I
1 certify that in the performance of the work fa which this ,
permit is issued,I sholl nnt emplay ony person in any manner SINK CITY TEI.N .
so as 1a become subject to the Workers'Compensation Laws. p15HWA5HER � •
/ connRacroaR,C.R. Plumbin INC.
(Mte OpplicOnf CLO7HE5 WASHER � �
ADDRESS
a"ITICE TO APPIICANT: if, ofter moking this Certificote of I Z $ Ma T101�2
� Tption, you should become subjecf fo the Workers' SWIAAMMGPOOI.RECEatQR
..,.mpensa�ion proviaions of the tabor�ode,you most forfh• {qyyN SPRINNEER SYSTEM C4TY lEl.PJp, _
.. with comply wiFh such provisiona or this�,m�� �,ou � - ��N�.No. 336428 - "`. - �
deemedrevoked. � � wnT�tt+EaTER �, Ctn55 C-36 �
� UCENSED CONTRACTORS DECLARATION � . DiSiRiC7 ta0. vttOCESSED Bv
UAS SY57FM��. � :�Ok1FlET5� �� �
-l here6y.affirm lhoi!pm.licerued under provisions of Chapter 9 . ... ' .. ..� . , `Q . - -
, (commencing wilh Sedion 7000)of�ivision 3 of the Business pU7LEt50VER - � �
and Professions Code,and my license is in full farce and eHect. 5 PER SVSTEM ' � �� �� f��� -'� �� �- " � � � � �� '
. DAiE .f 'f��'3 v . V i
arEan►
UcenseNumber 336�+Z$ �ic.C�ass �'+-3E1 '
� i
� . _.. _. .::._
� RCR`Plumtiing G/I9/85 � ;
.... FINAI��
� Con}ra[tor � - Date . . . .. . .. . . .. . . .. . . . . BY ' � >
.
❑ . - . . . . . . - " . . . . . . . ..., ..._'_ "" _ . . . . . _ ' . ,y e
�am exempt v�er Sec. N }
B.BP.C.for this reason � -� � Z �
Plan check fee � :
" Date: � ' -' ^ -
- PLUMBIPlG PERMIT 455UING FEE� �(J (� � � =t�.i.:.� li .. t
Signoture �
TOTALFEE �Q�,/il �w • . • •5 i
0 o tJ f
Plan check oppl¢an� � . .���(�1
SINGLE FAMILY I .
HOME OWNER-BU�LDER DEQARATION Name • • � • • d e�`Fi�G�
re6y akirm rhat I am exempi from the ContraUor's license +� �
� .for ifie ioltowing reason(Sr[iion 7031.5,8�siness ond A��� � �1�,�Cf—�E,4�.
Profeuions Code�: City Tel.N - - -
❑ I,as owner of the property,will da the work and the �
str�cture is not intended or offered(or sole(Section �
7041,Business ond Professions Code).
CONSTRUCTION LENDING AGENCY -
I hereby offirm that there is a wnstruction lending agency for
�he performonce of the work for which this permit is issoed -
(Sec 3097.Civ.G.).
1
lender'e Name �
Lender's Address
I certify thot I hove reod this application and s�ate thot Ihe �
above information is mrred.1 agree to comply with oll CouMy �
ordinances and Stata laws reg�laling Plumbing,and hereby
a�thorize represeNo�ives ot�his County lo enter upon Ihe
obove-mentioned pr rry for in ection purposes. SEE REYERSE FOR EXPIANATORY LANGUAGE
� R.C:R. B�,t� 6/1,9/85
� Signature of Permil�ee Dote - - f
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