HomeMy WebLinkAbout10_29_1984 - 21073 PATHFINDER RD (3) YYORKERS�o�NSATioNOEcu,w>TioN � �� APPLICATION FOR PLUMBING PERMIT � - � ;'
I hmeby offirm that I hcve a cert'rfiwta of conseM to seli � �dqyy�q � ' . .
insure,M O Cert�fiCale of Workere Com.penaaffon Inauroixe, �CE 817(REV.10i81) . � � -
or c ceAified copy tFreraof(Sec.3@00.�ab.c.) � � � COUNTY OF LOS ANGELES BUILDING RNb SAFETY . :
���0 0984-1099�9om�ps�tel'q EIDpl0y2t'S j , , �
CpA(fied copv is herp6v R+rnixhed- � �
� � 'F�RAPRIGANTTOfILLINIPItMTORlYPE) � A�0� . ., . , .. . .
terlified wpy is filad with Iba eouny boilding inspec- �
NUMBER FI%7UREORI7FM � f{E t
tion departmanl. ���ry Diamond B�Ir � - � '
oaro1Q-2_9'.��.-Aaai�w�� Cee`�.P1um6in4 ��,��r � c :
CERTIf�CAiE OF EXEMPf10N fK4M WORRERS' DATH NB . - � (.RO55'S1: v t . .. . . �
. COMPENSATION 1NSUkANCE � SMOWFR �R . � . . . S
(Th�s sMlon nNd aot ba mmplrtad if 3he wiork Inrolwd Iry � . . � � �
the pormh 1�for ona hv�red dolfan jS10D}or lars.) �qvnTortv „�,�ss 210�9 Pathfi nder
I cerrify�haf in tha P���ce ol the work for wl�ich thie � . j
parmit�s issued,I shall ra�employ a�ry�Person in ary rtanner S�� � �n' , Diamond��Bar. �.�. .. '—
so m W bemme subl�fo tha Warkers Compenwtion Laws. � !
o�sHw�ee . cor�rRnnoR Lee's Plumhing
i
Oera applimn� � ctottiE5wn5MER . , � . �
. R AOORE55,
hpTICE TO APPLiCANT: If, ahr maki�thia CeAHimte of 2�Q7 �. Le AV$. �
E�emption, yau shwld berome subjeCt to the �Kll(orkers' Sw�mhu�c'roO��ra� �
ef1' � 44-U528 i
. CamPe�aarion prpvis�w�s of fhe taber Cede.Y�+musr fonh. �aMrt�SwtidiciFa sv57FM � _
wifh cam I with tueh rovisiOns or 1h1� 4rmit yhofl be STAiE - � IlC• �
daemed revcked. p � wnTEn�a7�t u�+SE wo. 3Q81��, 6 i
UCENSEb CONTRAtTORS DECtAR�+T�QM aSiRICr NO. ev
I here6y aNirm�hai I am litemed�underprovisiatqafaGhapter9 � �5��'�'- ��' � �
(cnmmenKirg with Ses+ion�00p)of P�riSron 3 of�he 6usinesa p�i�7g ov¢R . y i
andProfesaioroC.ode,a�mylicenseisin4vllfaceandeNect. S�b�� ��FtNAI VALIDA710Nr - � �j
�.. . DA'� •�"'` � V ,
liceme Nvmber�OS��Et-- - ��c.Closs �(� 9=
co�+.«rwLee's Plumf�Xng oO1e TQ-Z9-84 � �, Bva. _ m
r G �
� ❑ I am exempf�nder Sec.. .: . r .. � �'r-`.. . .� . � 6
5 � �g "�0 8�� H �
B.sP.C.fw+m:.�n� Plan check fee � Z j
� Oate:�_ �PLUMBMG PERMIT ISSUMG fEE S , . � . � --
Signoturo � � . �
� . . � TOTAL fEE '��`� �
. . . -. Plan check applicant . � .
SINGIE fAMIIY � �
HOME OWNER$UIIDER OECIARATION Name .. . . . .. . . . . _�.F��F1
I tro�eby offirm that I gm exvmpt f/om ihe Conhocta's liceme p�dresp � �
Law for the followin renson Setlio�7031.5,Bvaineaa and -- - -- . . ... �tt• • • ` •�Jr �
Professioro Code): . � �ity�" � Tel.fao. . .
❑ I,al owner of�he proparry,will do�he work and the • . - . � � � � � •L�'�.�� �
ahvcNre is�o�intpndpd or oNered fw wle(Seclion , . .. . .
7D44,Business ond Prafeuiorn CodaJ. - . . . . . •�>C��::i�? ;
CONSTRUCTION LENDING AGENCY . .. � . . . _ . . . � � � � I.L C�',—�� I
�hnreby affirm rhat rhere is n wnahudion le�ing a9enay far , - '
i 1he perfomronce of the work fw whieA d+ia permit is issued � . . . . . . . � �
(Sec.3097;Civ.C.). �
. I
� Lemder's Nome - . ... .. . � . �
lande:s Addresa . . . . . . .. . �
I ttnify�hat I hove read this application und stale Iha1 1he . .,_ � . . �
above information is caren.I agrea tv wmply wit6 atl Co�my . � . �
ordinances and State laws regvlv�ing Plum6irg,and hereby . . .
aWh rize represenMtivey ot Ihis Counly to enter�ppn tha .. .. . . . . . . . .
a�o -memioned properry for inspec�ion p�rposes. SEE REVERSE FOR EXPWNATORY LANGUAGE � �
10-29-84 j'
' noture of Vermitl4e - Date � � -
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