HomeMy WebLinkAbout03_27_1985 - 21073 PATHFINDER RD '"'°�'�""�"�,T'°^'°�"T'°" APPLICATION FOR PLUMBING PERMIT °
�hercby�offirm that I Fave o certifimre of mnsent to self lyqyy�p . � �
irqure,or o mrtii{cqte of Worken Campensarion Inwwnce, CE 811(REV.10.�81) . . . �� � . 1
or n eenified copy thEreof(5et.380D,iab.C.) /� � CrSllNTlf C3F LD5 ANGELES BUILDING AND SAPETY {
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P❑oliey No. .. ._,TComppny ��T . . . - _ . . .
Ctnified copy is hem6y f�rnished. �
� Conified mpy is fited with Ihe county 6uilding inspec-. _�a������N������ BUILqING '
�� o2/D73 I��i��iND�, i
NOn de enL � � NUMBER � FIXTURE Of1 t1EM � � FEE ��//� �
/ . ,J/f . . . LOCJLLIiV '� v/Y
pnte . �'S Applir,ont�`r/"��� . WA�a� . . . . i5F.4�5i i
CERTI IfAIE OF EXEMPTION FROM�WORKERS' eniH iue . . QtOsS bT. ;
mu�snTioN iNsuwaricE �R � y JY/�P ;
s�o�r�a
(Tht�seetien nNd nori b�eomplatad ifihs work Imwlved br � ,
ths p�rmif is(br one hvndnd��d011un(5100)or(o�sJ -...� �AVAiOev . - �,poR�55 t'f Z / e �
I cenify d�at in the performance of fhe work tar which�his � �� -
pprinil is ip�pd.I thpll+m10TPlOy qny.ppnon in U�lymnnnEr S�NK � - C,ITY ���, ,��� TFt.rp.
ao w ro become subjecr�o fhe Workers'CompensoYfon bm. �/ �—
. . .. � MSHWAStER� : . COMkAROR . �/� - ��
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Dofe . e�licuM CIOiHES WASHER � ' . i
NOTICE TO AP�IIGANT: li,che�making Mia Cerrlfitote of ������� _ �� . � i
EYemption, yov�ahould bacamo wb"eU Yo fha Worker� �
Compensatfon prwiaiam of rhe labor�cde.Yvu mys�forth- . GTv�� iEl. ���9 1
with compiy wifh such proyisions qr 1hi#peYTit sholi ba ���INKLERSrSTEM � d �7Ah L g •1
deemed rcvaked. �WA��p�g� � UCFNSF NO. ,' � %�
. LiCENSfD CONiRAGrORS DEGlARA71Q�1 . � OISiRK7 NO. BY �
� �hambr arWm fr,ai I am(icen;od w,ae.pravision}�E�F�pprer v � � cnssXs�F�M � ouners
(cotnmefxing rnlh$eclion 70pD)of birision 3 a1 tf�e 9usimss q11IEi50VER - - . �" �
andProfessionsEodp.ami�myli�emeninfpllf.qlAcaondeffecL SPERSYSiFM �Np� d
ticenae Num r
����� 1�c.Ctau`� Dq� a/�b� , VAUDATfON � ,
Z „i �FINAL � � O �=
COnfraclw ,��Ote � _ �/' :� - . . HV � f
W
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I am exempi urdm Sec.
B.dP.C.for this reason - ' � . . ' . - . . Z .
_ Plpn check fee �3 7 z a.A
�re:
�unnHm�G vERnnir issuir��5 �� . . . . � —
sigrKrt�••• _— � .
_ TOTALfEE Q . ��•,• ����� •
. � � 16�0� i
- Plan check aPPlicqnt
s�n�ctE Fannur 0 u 1 2—8 5
HOME OWNER.BUILDER OECIARATION Nome . . . . . . . _ .. . .
I fipreby cff�rm thot I am e:empt from rhe Confraetor's tieense Address ��
lnw for fhe followi�.eoson(Secrion 7037.�,Businesf and ,
Professions Code): . � C�iy � Tel.No. " �
� �,as awne�of tha properry,will do fhe work ond the � -� . -
ahucturo is not intended o.offered for wle(Secfion - � . . �
7044,Busineu ond Prafeosions Code�. . - .
CONSTRUCTION IENDING AGENCY _ . . � .
I hereby offirm Ihal ihere is a co�ruetion le�ing ogerrcy fw - _
�he perform4nce of ihe wo.k 4w which thia oermit i�Iuued _ . . . y
lSec.3097.Civ.C.). - � � � -
j
lendx's Nome . ... � . . . . . . � . . I
i
Lendd's Addresa . . � . . i
I cenily IMt 1 hove read this application and atafe ihal the - ,� � }
above information n corrM.I agree to comply with ali County " {�
ordinance�and State lovrs regulatmy Plumbing,and hereby . }
authorize represanMeives of fhis Counry�o enter upon the � � - � � - � - ?
a6ov -mentioned propeny for inspecfion p�rposes. � � .• . . � �
� r SEE REVERSE FOR EXpLANATORY LANGUAGE �
c� a`� i
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