HomeMy WebLinkAboutN/A-...... , ie, ,
-,certificate of Workers' Compensation Ins,,, or a certified co y thereof (Sec. 3800, Lab, C. )
83mCKg956-104CPA
Policy No. Company netna
Certified copy is hereby furnished,
Certified copy is filed with the cou'�ty building inspec-
tion department.
Date _8 22/84 Applicant The Anden Grzg,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the W_• Involved by
the permit is for one hundred dollars lr"UO) 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 8/22 84
I am exempt under Sec.
B.&P.C. for this reason
Date:
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 Continental Illinois
Lender's Address 399 Park Ave., NY, NY 10043
1 certify t at I have read this application and state that the
above i ation is correct. I agree to comply with all County
ordina s and State laws regulating Plumbing, and hereby
outh t r resentatives of this County to enter upon the
abo e me o e pro for inspection purposes.
8/22/84
Signatur o Per flee Date
Will
FOR APPLICANT TO FILL IN (PRINT OR TYPI
JMBER FIXTURE OR ITEM @
WATER CLOSET
BATH TUB
SHOWER
'��LAVATORY
CLOTHES WASHER 77_
SWIMMING POOL RECEPTOR
f LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM I
Plan check fee
PLUMBING PEF
Plan check applicant
Name
Address
City
IIT ISSUING FEE $
TOTAL FEE
Tel. No.
BUILDING
ADDRESS 24283 E. Seagreen Dr.
FEE
LOCALITY Diamond Bar
NEAREST i
Golden Springs
CROSS ST. � gs
OWNER The Anden Group
MAIL
ADDRESS XNEVE 1074 Park View
CITY 9I ' 67-9�
CONTRACTOPThe Anden Group_
ADDRESS Same
CITY TEL. NO.
STATELICENSE NO. 371580 CLASS B
DISTRICT NO.
PROCESSED BY
FINAL
DATE
VALIDATION
FINAL
BY
SIM