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HomeMy WebLinkAbout1066 SUMMITRIDGE DR (5) ,� '�,q�.°� '°.,,, WORKERS'COMPENSATIONDECLARATION � . � APP��ICATION FOR PLUMBING��ERMIT � '��<6 hereby affirm ihat I hove a certificote of consent to self �yqdy�q � insure,or a certificate of Workers'Compensalion(nsurance, CE 8�7(REV.10/Sl� , o�a certitied copy rhereot�Sec.3800,tab.C.) ' COUNTY OF LOS ANGECES BUILDIPIG AND SAFETY 6084266 Great American Oq No. Company • . Certified copy is here6y furnished. FOR APPLICANT 70 fILL IN(PRINT OR TYPE) BUILDING '�Certified copy is filed wiih iHe county building inspec- nD�RE55 1066 Summitri = tiondepartmenf. . NUMBER FI%TUREORITEM �rt ,FEE �OCALITY 1'R# 425�1, j,Ot 15, Diamond Ba.r � � ��I�S�I LQB.YCTtOII BT'OS. � WATERCLOSET �"`� ��Date Applicani . NEAREST � ' � CERTIFICATE OF EXEMPTION FROM WORKERS' � eATH 7U6 �"7 .� CROSS 57. ! � ' COMPENSATION WSURANCE ,�.-- OWNER M.J. 13rock & Sons II1C. 7.. SHOWER Z,' - '(This sectlon need no4 be compleled if the work involved by MAiL P.O. bOX 350 ;6 fhe permit is for one hundred doilara(5100)or less.) LAVA70RY � ADDRE55 '`I certify that in the performance of the work for which this SINK � CITY Brea CA 926zz TEL NO. rjz9—tg].`�� a permit is issued,I shall nof employ any persan in any manner i�,,.`�/ f � �so as to become subject�o the Workers'Compensation Laws. . � OISHWASHER "J CONTRACTCjqE,+a,VCI'tOR BTOS.� IRC. �� -' �Date ApplicaM CIOTHES WASHER A�ORE55 P.O. BOX 1 11g � .� `NOTICE TO APPIICANT: If, after making this Certifimte of 7 � �v �'�mption, you should�become subjecf to ihe Workers' SWIMMWGPOOLRECEPTOR CRY TEL NO. . �mpensafion provisions of ihe Labor Code,you must forth- LAWN SPRINKLER SYSTEM Irvine CA Z�]1 8�7 —11�� � � . !:wifh comply with such provisions or this permit shnll be STATE 1919b9 'IC. C36 �..deemed revoked. f WATER HEATER LICENSE NO. CLASS � . LICENSED CONTRACTORS DECLARATION �ISTRICT N PROCESSED ev — ;I hereby�'Ftirm fhat I am licensed under provisions of Chopter 9 � GAS SYSTEM OUTLE75 �(� ..�.(commencing wifh$ection 7000)of Division 3 of Ihe Business � OUTLETSOVER "�and Professions Code,and my license is in fuli force and effed. f 5 PER SYSTFM -� FINAL �- VA IDATION �: 191969 C36 o'°TE �-- �J n -License N,vmber Lic.Class ; Leaverton sroS 3/19/87 FBIY AL c,. Coniroctor pote � �/ O ❑ I am exempt ur:der Sec. � � t - B.&P.C.for this reason ` i,�! p � Plan check fee p �S Da�e: � � � 'y� � PLUMBING PERMIT ISSU WG FEE$ �..�� � Signature t, z()��.(7{{ fi. x TO7AL FEE ('�I.. C'Cry � r� . � Flan cF�eck opplimnt ��� ��� � �� . SWGLE FAMILY � I ^ I C Q,C Q HOME OWNER-BUILDER DECLARATION �? Name � �� ��!hereby affirm that I am exempt from the Contrador's I.icense ! z ��'�` iaw ior�ne roiiowing reason(Seciiun 7"v3iS,6usinese unei y Address A " � [:�,�ei c: Professions Code}: j( City Tel.No. ��'Z�...,Ei�' ¢ ❑ I,as owner af ihe property,will do�he work and ihe i structure is not intended or offered for sale(Section ' �; 7044,8usiness and Professions Code�. '� � � � LONSTRUCTION IENDING AGENCY '� E I hereby ntfirm ihai there is a consiru<tion lending nqency for i the performonce of the work for which this permit is issued x (Sec.3097,Civ.C.). 1,' � I� � lender's Name t ,'' � �' Lender's Address � �. I certify that I have read this application and siote that the � ." ❑6ove information a mrroct.I ogree to mmply wilh all County � ordinonces ond Stote laws regulating Plumbing,and hereby ' � �^ ❑uthori�e repre'senlativ s of ihis Couniy to enier upon the. � j bo�e-rnenlioned pro 1 for inspadlan pu pnses. 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