HomeMy WebLinkAboutN/A,reby affirm that I have a certificate of consent to self
—ire, or a certificate of Workers' Compensation Insurance,
8 pr�T�®r}� c{ �y4tbof (Sec. 3800, Lab. C,)
Policy No. 1l1 C: Company Aetna
Certified copy is hereby furnished.
El Certified copy is filed with the county building inspec-
tion department.
Date 8/22/84 Applicant The Anden Group
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section, need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number 371580 Lic. Class B
Contractor The Anden GrOUP Date 8Z22/84
IDI am exempt under Sec.
B.&P.C, for this reason
7ea667a
APPLICATION
CE 817 (REV. 10/81)
FOR APPLICANT TO FILL IN (PRINT
OR TYPE)
BUILDING
ADDRESS
1160 N e Flyinq
Hill
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
Diamond Bar
WATER CLOSET
NEAREST
CROSS ST.
OWNER
MAIL
ADDRESS
The Anden Group
1074 Park View Dr,
BATH TUB
SHOWER
LAVATORY
SINK
CITY
Covina
ff067®9541
DISHWASHER
CONTRACTOR
The Anden Group
CLOTHES WASHER
ADDRESS
Same
SWIMMING POOL RECEPTOR
CITY
STATE
NO. Q 715H 0
DISTRICT NO.
/ 0
TEL. NO.
LIC.LICENSE
CLASS $
PROCESSED BY
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
VALIDATION
DATE
FINAL 4
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE $'
TOTAL FEE ®��}
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of.the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Le A ress399 Park Ave-. NY, NY 1004]
I cer if t at I have read this application and state that the
ab i ormation is correct. 1 agree to comply with all County
or i a ce and State lows regulating Plumbing, and hereby
a t iz representatives of this County to enter upon the
e- ention ,d��o/party for inspection purposes.
8/22/84
not re of Permitte Date
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE