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HomeMy WebLinkAbout1180 DIAMOND BAR BLVD (17) . � ��:��VORKERS'�COMPRNSAT[ON DECti:ARAT[UN . - . ��ssnss�r � � �� � ����w /�7 � � i;here6v a��,rm tnat � h��e a����t�f,��tr �����Se„t«-S�if ==EB,��z-eo, -'_AP�PLICA�.TION� FO'R PL.UMBI:N,G ,�.PER.MIT 1.�. y�]� : . insure,or a certificate of Wprkers'Compensationdnsurance,or ,± � � � . � ��'- � �� � i 1 O�i a�ertified copy tnereof�c 3800,Lab c) / �� COUNTY OF LOS ANGEiES BUILDING ANC�SAFETY p GG1�J'J9 J3k•7s`ll �:w�r��.:�=�tr..f?��.��l.er� � . ,j 7 � .Pnlicy No. Compan� � ;.- . . . � ����� � '#� -C1�i��,t�.�kc... �.r��7`��_ C. �,k'-.ia��c . r r .�.� C�rtified copy is he[e6y furn�shed. ` FOR APPLiCANT TO FILL IN IPRINT OR TYPEY Bu�LD1iVG �j ,✓< + � �(�p� ` NUMBER Fi7(TURE OR ITEM • FEE '0`DDRESS R tq'yp't(yt, � �3.�6✓' � C'°"Y ac �� ('ertified copy i5 filed with the county building inspection �OCALITY � �epartment.� WATER CLOSET 21l�. %� t+`J/j --��f"��':�V1 �`' �'�� 3Date�b��'.l��f' APPlicant��''�i,SC,�"r ���.h('r� NEAREST - �{ BATH TUB � CROSSST �'r +� �'`Fi�1�� /"1��• ;��� C1:RT1 FICATE Oi'EXBMPTION I�ROM WORKEILS' COMPF.NSA'LION INSLIRANC6 SHOWER OWNER . � � LAVATORY �h � MAIL , . ��� � ;(This section n�d not 6e completed if the work involved __ '=� � �� A�DRess �_ ,by�the permit is for one hundred doilacs($100).ur less.) SINK � � , ���r� CiTY TEL.NO. . �'. ��'�I certify that in�the perfurmance nf the work for which this DISHWASHER � 1// �7 ,�( � ,�, CONTRACTOR �'�permit i5 Issued,i�shall not employ any person in any manner `�U r C ��' /✓ :�so us to becnme subject to the Workers'Compensation Lxws. CLOTHES WASHER � �"� ADDRESS / ,{..b��� � -�!]ate Applicant : � �� /��S ��- ���� �����/ ��' SWIMMING POOI ftECEPTOR - t�, �.NOT[CF.1'V.41'YLICANT:If,.after making this Cer[ificute of CITV �'��'� dg,�_� TEL.NO. JA `:�xemption, you should become sub,jec[�tn [he Workers' LAWN SPRINKLER SYSTEM STATE ! LIG �'�' :�Compensatiun provisions uf the Labor Code,you mwt furth- yVqTER HEATER .;r LICENSE NO.���5/d73-�� c�ass G 3�w ���with cnmply with such provisiuns or this permit shall he ��"'� DISTRIGT NO. PR04�6SSED BY �:deemedrevoked. - � GASSti'STEM ,�OUTLETS ` ' � i ✓I ���� WCLNSED CON'i'RACTORS UliC1,ARATION OUTLETS OVER ^I t' �r-y, e:£'i'r-'"e.� ' y+ -t hereby affirm tYnt�l am licenseJ under pruvisions of Chapter 5 PER SYSTEM � 6���9,(commencing witli Section 7000)of Division 3��F the.Busi- �Y �,y �^^ �.,��f DR E� ��/p, 'VAUOATIOIV � �ncss and Proft�s�ons Code,and my lice»se is in fuil fo�ce and � J :-etY'ect. � 0� f ✓�. I.Y, �"; � � l(� 'p� . � [/_ (p �` . FIMAL � i ce��se Numbcr 1'"'�,d'S'� Lic.Class --5`P yj ) ' �"' f', '1 �� gy. �'��� ; . �.�i / r�'/5�, = /� . � T /�Q�P ...7� ... ;P..'� 1 l�l/1 � �C��t�i�T�rl�.h �"f e � �iDate_ID -3I j , �1 ��' �� �� �f�� ��{�.a �.t��� �,��� I nm exempt from the ficensing feq irem nts�ax 1 am a ' P�an ChBC�C f2@ . � ' yj � t licensed�architect or a registered profeasional engineer pLUMBWG PERMIT ISSLIiNG FEE$ � ��r7r') �� ��"'"`�''�'���� � xcting in my protessionai cupucitY (S�ction 7051, Bu�- � � inCss and Professions Code). TOTAL FEE 7 " � µ'� '�.J�i �Lic.or Res,No. llate �. Plan check applicant -L.7L•'C_ TIDP! ��Nama � � AOMEOwNI?B.-RUq:UL:I � renn �� 1 bereby affirm that I am ezempt t[om the Conlractor's � Atltlress _ -�.. �. Licensr,Law Fn�rh�e..n.... o _.....,. i __. .,�....�, ,,,.5� �pCItY Tel.No. r ness and Profassim�s CodeJ= . �, � I,as uwner of the propertri am exctusivety cuntracting �,t� .,.. . � with l'scensed contcact�rs to construct the project . � (Section 7044,Business und Profescions Code}. � - � i'.;> a c F, , ,. . CUNS7'RUCTION LENDING AGL:NCY 3 . ;��'�'.';,{,;��.� . � I I�ereby affirm thut there is a Construction lending agenCy � . - � Cof the perfonnance uf the work for which this permit is ' , ' i . �- t. � -4�� .. issued(Sec.3097,C.iv.C.). � � � I,endar's Name_�__ . � � f i, c'G."C;�i �Lender's Addcess � � '�� I certify that I(iave read this appiication und atate that the , � � ���a6ove information is correct.]agree to comply with all�Cou�Hy SBIs itLVERS�FOIL EXPLANA'1'UNY LANGUAGF. - . � � ordinances and Sta[e laws regulating Plumbhtg,�nd hereby , �� . �'-authorize repreeent.itives of this County to enter upon the � bu�menti�ned rop rty tor m,�,c',/e'c[ion Vurposes. � � ✓%7'�'.e•,� r' �'�,�.Ga� j��.)'�G Signature of Permittee Date � � � '. �- „ ;c n � = c� c� � c ,._.. - .. Dz � z i-� D:C O D D�O z _. . O r cn j cn tn i . , ,.. . . .. . . . : . .. ..... ....:... ... . . � .,. . ... ,,., ...._ . . :�.. : m _ — -i �� `� �< �-o � �,�. 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