HomeMy WebLinkAbout1763A (449) WORKERS'COMPENSATION DECLARATIOIV qPPLfCAT10N FOR PLUMBIMG PERMIT �
I hereby offirm Ihaf I have a cenificate of cansenl ta self �yqyp�p �� `
msure,or a certificate of Workers'Compensation Insuronce, �{817(REY.�0/81) �
or a certified wpy tbereof(Sec.3800,�ab.C.� COUNTY OF{.OS ANGELES BWLDING AND SAFETY
aw����omPa�Y FrPmnrtt TttdPmnity .
Certifted copy is hereby fumished. .
� FOR APFUCANT TO FlLL IN(FRINF OR NPE) &UILOING
Geh�fied copy is filed with the county building inspec- ADDRESS {�
tiondepartment. . NUMBER FIX7UREORITEM � �E �p�q�RY Diamond Bar
Dute G��Q�Sl S p, 4i ant WATER CLOSET
��� PP 4 c'EQossss. 60/Philli s Ranch
CERFtFICATE OF EXEMPTION FROM WORRERS' � 6ATH TUB B�
coa+e�nisanoN�n�suanNce SHOWER ow'',�R South Coun r C
(Tkic cMion xoad not ba eompbtad if Sha wwk 1».elrod 6y MAII
Iho pormN is fw ortQ h�odrod dollars(S1U0}or ksi.j lAVATORY ADDRE55
i certify thuF in the periormance of the wwk for which ihis
permif is issued,I shall nat employ pny person in ony rrwnner SINK CIFY TEL ryp
so as�0 6ecome subject lo ihe Workers'Compensatian laws. / DISHWASHER D �1,7
( � CONTRACTOR R�C•F�. Plumbin Li�C.
Date epplicnnt CLOTHESWASHFR A�DRE55
� '10E TO APPLICANT� If, aker making this Certificate of 2 � j"jg OI�
��, nption, you shouid become subject ro the Workeri SWIMMINGPOOtRECEVTObt CtTM . ��
. Compensarion provrsions of rhe Labor Code,yov must farth- �.qwN SPRitiKtEa Sv57EM -
with comply with s�ch provisions or this permit shol) 6e STATE •' • LIC,
deamadrevoked. � WATERHEATER , ���E�r�o. 336428 c.enss C-36
LlCENSED CONTRACTORS DECLARATION q�R��,p� ���y
.� . . - GAS SYSTEM �- � OUTtETS- .- , �- � .-.. .. --. . -'•
Ihereb aNirmihat4amlirensedunder "�- � � � � ' '�� ' -�'�--"" '--"- -�
Y provisians-oEChapier4 . . - , -_--. -_- - __-- -.-_'- 3
(commencing with Sedion 7000}of�ivision 3 of tha Businasa � OUTLETS OVER . ,s�
and Professions Code,.nnd my licewse is in fullforce and e4fect_._ -. - 5 PER SYStEM. .- .. � �
. . ..- -�--.... .-- -- ... . . . .. . ... FINAE.�:..._ � .. . . ...
� .. . ,. � - . .. . ... . . . .... . . ... . . ' �
_. '
DAre /3��'.���y� VALIpATFON .
License Number�Eic.Ctass__�y„_��„ ._ _ . . . . _ _ . _ .___.� g
� . . .___ _-- � -_. . . .. . . ...... - � - - ' t
.. _ . _ � _ � ..� �_ _ _ r„s
Controctor RCR PI.tIIIlI71I2�6are 6/1�4/85 ` � -� . . � sv""`�r . . � . � � . • !
�, a
❑ ;� •
t am exempt under Sec. y �
. . .9.B.P_G for this reason . . . . �. � .. . . . . .. . _ - .. -. .-. --...-'- ' --- -- - ��-f
. ... . .. .. .. ..
--- Plun c�eck#ee .
. . . . . ....... . .. ... .._. . -. _ _ ....-. .. . -. .. ,< _ e
_: . .-.... .._:,._.. , ._: '- . : . . . .. . ..... ., _ :
� Dote:•� _ .... .. ..... . ........ . ...... .... . _ .
_. .. . ..�. _ �_� _. .. . . . � .:_ � � -- �.:� pLUM81NGRERMF7�fSSilINGFfE 5-�- . -� .q-n. __��.- �-�_._: .�-��...� -- .2.:��.�s7'-t5�-��. � g
Signature ��.� �-�.. . P
- . � TOTAL FEE 7�-P�' . . �• ••.�' '.5. . i
� Pian check applicont � � • '•7 6,�j� +
SINGLE FAMILY R.C.R. PLUl�ING . INC:
.. f HOME O'�NNER-BUILDER DECLARATION Name � . • • �7 b rJ O� `
-ay,E •by affirm Ibat 1 am exempt from the Controttor's License gT1Q 2$, Ve. , . � . ,... . . � i
Law for the following reason(Setlioa 7031.5, Business ond A��e� ' " � , �f�O at��- �
Prafessions CodeJ: City Tel.N i
❑ !,as owner of the properry,will do the work a�the - ' �
siructure is noY intended or affered for wle (Section �
7044,Business and Professio�s CadeJ.
CONSTRUCTION lENDING AGENCY . (
I hereby offirm thai there is a mnsiructian lending agency for
the performance of Iha work for which this permir is issued
(Sec.3097,Civ.C.). -
Lender's Name
tandar's Address -
1 terfify ihnt 1 have reod this opplimtion und state thot Iha �
above informa�ion is correct.I agree to comply wilh all County
ordinonces and Stote laws regulating Plumbing,ond here6y
outhorize represenfatives of ihis County to enter upon Ihe
obove-mentioned p�o eny for inspeUion purposes.
t SEE REVERSE FOR EXPLANqTORY IANGUAGE �
R. i�.�
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