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. E
i . rJ SEF REVERSE FOR EXPLANATORY LANGUAGE �
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