HomeMy WebLinkAbout1762A (449) WORKERS"COMPENSATION DECLARATlON APPLICATIOM FOR PLUMBING PERMIT � �
I hereby offirm ihn! I have a certitimre of consent to self �yq6plp � 1 � �
insure,or a certificate of Workers'Compensafion Insurance, CE 817(REV.70/8t) d��Y �
or a terrified copy ihereaf(Sec.3800,Wb.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY
O�}�1��5�9Company T�'ramnnt Tnriamnity i/��/
Certified copy is hereby furnished. , '1`tt�d'
� FOR APPLICANF TO FlLL IN(PRINi OR TYPE) BUILDING q _
Certified copy is filed wifh ihe county bui ing inspeo- ADDRESS �/ �
liondeportment. NUMBER FIMUREORIiEM Q fEE 40CALITV Diamond. Bar
Da�e ���rAppli4ant � � WATERCLpSET { NEAREST
CERTtfKRiEOFEX€MP710NFROMWORKERS' BATNFtIs � .— �r�sT. 60/Phillips RdTtC�t
COMPENSATION INSURANCE L -
SHOWER OWNEN SO'U.tl! COUTltr Ci�Y
(Tbla wction iwed not bo compktod if fAe work famtvod by �IL
tka parmit is tor ono huwdrad dollora(ilUO}w Iscs.) � fqVATORY ADDRE55
I certify that in the perforrrtance of the work for which this
permit is issued,1 shall not employ any person in any manner �NK CI�Y � 7��,
so as fo become subjed ta ihe Workers'Compensolion Laws. DISHWASHER ` •
_ CONTRACTORR�C.R. Plun�bin s INC.
Dofe epplicaM f CIOTtiES WASHER � ADDRESS
NQTfCE TO APPLICANT: If, ofter making this Certifimte of 12785 Ma noZia Ave.
t �nption, yoo should become su6ject ta the Wo�kers' SWIMMING FOpL REEFPTOR
F .npensation provisions of fhe tobw Code,you mvst fortfi• ��TY ' • TE�.N6. _
wilh com I with suth IAWN 57kINKlER SYS1ENt p .
p y prorisions nr this permit shail be
deemedrevoked. NtATERHEATER �i,�No. 336428 �A� C-36 ��
UCENSE�CONiRACTORS DECLARATION q{SiRlC7 ... �g gY
1 here6y af4irm that I am(icensed under provisians o4 Chap�er 4 GAS SYSicM OUFLETS t
(commendng with Section 7000)of Division 3 of the Business OUTLEfSpvER � i� �
and Profestions Code,ond my licensa is in(ull force and effecf_ 5 PER SvSiEM FINAL � �"
. License Number .....Lic.Cfass�. . . . . . . . � . . . . . OATE . .. . . � �
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co���a<<o�.RCR P ltmib ing,�;e 6 f 19185 ar � �
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I am ezemp�under Se�. �
� B.BP C for tb s ea on . .. .� E
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Pfon check applimnf � � � � � �
� SINGLE FAMIIY I • �7 6 5 O �
HQME O�M1'NER-BUILDER DECIARATION Ncama R.C.R. PLUMBING� INC. • • •i G 5 C u �
re6y affirm tha�I om exempt from fhe Controctor's License 1 y��
� 'for the faltowing reason(Section 7031.5, Business and �feu � II�I,�9�$5 �
� Professions Code): City Tel.N -
❑ I,as awner of the property,will da the work and the , � �
structure is not intended or oHerad for wle (Seclion � . �
7044,Business and Pro{essions Code). �
CONSiRUCT10N LENDING,4GENCY
I hereby affirm that there is a constructlon lending agency for � �
the performance of ihe work for which rhis pe�mit is issved � �
(Sec.3097,Civ.C.).
tender's Name
lender's Address
1 certify lhat 1 have reod this application and stofe that the - �
above informotion is correct.1 agree to comply with all Coonty �
ordinances and Sta�e faws regu�a�ing Plumbing,ond hereby
outhorize represantaiives of this County to entar upon the � �
above-mentioned proparfy for�nspection p�rposes.
�(�,r � n. i � � 5 SFE REVERSE FOR EXPI,ANqTORY LANGUAGE
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