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Home My WebLink About1661A WORKERS'COM�ENSATIONDECIARATION APPLICATIQN FOR PLUMBING PERMIT /� . I hereby,oHhm iha�I Fave a certificote of consen+to ssll 76A887A �,1A f ✓�� . insure,or a car�ificate o/Workers'Compenaation insuronce, CE B1I(qEV.8/B6) �-� � � � A /,� � � 1 I or a certifisd copy�henof(Sec.3800,Lab.C.) � � � . IJ P❑olicy No.�p�gp�_compony • COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Ce�tified copy i:bereby fumished. TrdCt 43728 Ph.3 � � - FOR APPIICANT TO FILL IN(i1tINT OR ripE� BUIIbING , Ce��ified eopy h fibd with tM rouny buildinQ Inapeo- AOORESS 20744 E. Crest Lane ' . rronde ime�f. NUN�BER FfMUREORITEM � FEF PO' ��T�' Diamond Sar ou�e f�(�rjs7 napuSomQ*anS7 na-P r-�,�f'r F�}� 8 wn�aaoa�r 6.00 48 00 �naEsr CEKfIFiCATE OF EXENWTION FROM WORKfRS' 6 eATH rue 36 00 �ST�Pa thfinder Road COMPENSATION INSURANCE SFqwfR �W�R �TtIB W1.1.22dII1 L OTl G�P!!1 an (Tbls��celon nqd eot 6�compl�t�d�f�h�work In.olwd 6y Z . . th�p�rm�t is ior on�hvndnd dotlars(ttp0)o.i�u.) 13 uvnTORv 78 00 ��55 19 COr Tate PIaZa � 1 wrlify IMaI in the peAormonce of the work for which�his permit is�a+ued,I sholt not employ o�y penon in ony manner Sm�K CITY NBW z't Be3Ch h� �'833-3600 � zo os to become subject to Ihe Workeis'Compeasofion lows. DISHWASHE4� Z4 �� °NTRA�T°R Oranqe Pacific PSbg.,Inc. Dob � epplicanl Q CLOIHES WASHEA � ZQ 00 � NOTICE TO APP1,{CANT: If, ofter makioq Ihis Certifico�e o! � A�� 1240 N. j7dII Buren Stllte 212 ' Eaemp�ion, you :hauld become subject to the Workers' SwiMM1NGPOOtRECEFiOrt - � Compe�sofion prori9�Oni OF Ihe�ObO/CodO,y0u musf forth- �AWN$PRINKLFR SVStEM ��ry Anaheim '928p7 ��•^1O�630-4090 . wi�h comply with suth provisiona o� fhia permit sho�l be �,��,pg39226 ��C-36 deemad revdced. WATER HEATER IICENSED CONTRACTORS DECLARATION OISTRI�T NO. BY � I hereby offirm Mwr I om licenaed wdar prorisiom of Chap�er 9 4 GAS SYSiEM ZQ OU7LEi5 2,Q QO . y (commencinp wi�h Section 7000)of Oiviaion 3 oi tha Bosineas WiLEiSovER � . G. � ond Professions Code,and my liceme is in full force ond effect. S vER 5r5TEnn F�� p oA� � c,,-;. VA41DATtON � License Number 4�Q,226 Lia Ciasa C�^36 � �"-�J OC Orange PdC1f1C. F�N'A� �� - � ��, Conkpdoi Dole $�1 j,�R7 BY ~ i • � ' ❑ I om esempr under Sec. � � x �. B.BP.C.for}his reoson Plan check fee � �� °' pIUMBING PERMIT ISSUING FEE S ID 50 - , Signnture ' � TOTAL FEE 310 50 �`1661A Plan chetk ppp{icanr � . � SINGLE FAMIIY . . � �j� • � e,-rj HOME OWNER-BUIIDER DECIARATION Nome � I ^�� J S^ 1 heroby oifirm thct I om exemp�6om ihe Contracror i Ucenss � ,qddre�s � � Law for.rhe followinQ reeeon(SsUlon 7001.5,8u�i�eu ond � _ �. Professiona Code): City Tei.No. �51C�;G� �, ❑ I,as owner of fhe propeny,will do the work ond the . � O f.� 4"r>7 strucWro ic not intended or ofiered for wle(SeUion � � , � - � , 704d,Bmioeu ond Rofesaiona Code). , CONSTRUCTION LENDING AGENCY - � : � " �� I hereby aN(rm�hot Mme is o conshuction lendinq aqency for � �be performonce oi rhe wwk for which this permit Is I�aued - � : (Sec.9097.Civ.C.). �� Lender i Nome � �lender'c Addrefs . . . . . . � 1 certify Ihul 1 hore read this epplimtion ond cbte�hat fhe ► � ubo�e infamafion tf correct.I aqroe ro comply wi�h oli Counry � wdieunces ond State lows reguloling Plumbioy,ond hereby . authori:a roprosanWtives of this County�o enter upon tfre _ � � abovs-menNoned pr perry£or impeciion purpmn. SEE REVERSE FOR EXPtANATORY IANCUAGE ��i . � ��/ ' Siqnowre of P rminee Da�e ... . ,. , . . , . . ._,.. _ - - , � - • . , : , .. _. . i ^. . . _ ., .: _ , . nFF�.ovsis on,r i-see�nor�ss�rr.:.ru:e i•�SF=co��s r:or.s � . � , -" -� ' .t,��[�_� t �qr'.: i UM1�EF SlA6 V.O^nK .. — � . . .— . � . , - ' r - n - �j ' h � '�`� � ROUGHf1U;:��,:w...._ .n ` , . .. . .. ._..1 ........ .. ,... .. ._. ..._ _....._ ...... L h. I L��.. I - t 1( '. � ..o .S CI�J IiJI 5 ' �as oiai�u� {��4=,J !� .. �n . .,, „ �- , ,... . _ �� f�.o� � c � �ni c�ry � �.��,�h . .,.. . �• F. � �. GFSL'EtiT ._ .. . "' '_ "_ '._ _. — . . . .. _ . . . . Icy�r_5'u F�..�rt�.f 1�.��nt�-ii._f. .Ilc�. lii��, i �tiVi . . . .. � ... •. � � _�_�".,�_�s_..,..,. :_._..._.._ .�__._.�..._._ ...__....:. . __._ ..... _.....r�_ . or repafr uny atrvclure p-fo�to'ils i . olso r HO' T�V/l.IEf.l1:A7;R..._._... "._'_ _._..." _—_'_ .--' — ..---. 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