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— "'°"KE"s•�°""�"s�T'°"°E�wR""°" APPLICATION FOR PLUMBING PERMIT � i
I heieby offirm tirot I have a ceriificate oF coneent�o self �bqyy�q �
insure,or a certifi[eta of Worken'Compansalion Insuronse, �817 IREV.10iB1)
or a cenified copy�hereof{5ec.3e00,tob.c.) COUNTY OF LOS ANGELES. BUILDING AND SAFETY
a�rr+oaRR� ���Ra�g,a��r trts, Cp. ldest i
Cer�if�ed copy ie hareby fwnish j
� . FOR APPIICANT TO flLl IN(PR�NT OR 7YPE) BULLOING .
CeNified mpy is filed with Ihe u ty b di g iMpec ADDRE5.5 � 2�# � E� �CO ��
'an d ent. NUMBER FIX7URE OR ITEM � iFF �
WATERQOSEi 1OCALT� D'�amond Bar � '
oa�� �aPPu�a�, N��T ;
RTIF TE OF EXEMFf10N fROM 4VORKERS' BATH7UB ���� i
� COMPENSATION INSURANCE � ��R OwN¢R �
(Thls saefion nwd nof be complefad if Ihs work Involwd b �i� �
1ha parmit i�tor on�hvndnd dollan(fr00)or(a�s.) IAVATORY qppR� - � �' � )
I cerNfy�ha�in�he performence oi tha work for which�hia
pBrmit is issuad,I:hotl no1 employ ony pe4on in pny manner 31NK CITV . TEL NO. '. , _
- w m ta bernme subject ro Ihe Workara'Compenatltion laws. ;
°1$`"""�"� CON'RACTOR Envlconmental en ineeri g �
�afe �pp1iCCM CIATNF3 WASMER - ADDRfSS 601. N, Po 1 a r
NOTICE�O APPLICANT: If, a}ter mvlcing Qhia Certificwro of SWIMMMGPODIaECEvroR - . .
Exemption, you shwrtd become�subjacr �o fhe Workers'
Compenwfion provisirn»cf ttre labor Code,y0u mvst fonh. �qyyN SPRp,iKtER SVSTEM °n -. �Q r a n e �.��i ' �82 a�
wi�h complr wiih wch povisiom or �his-perm+�aha�l be S7aTE uC. �
deemed revoked. . WqiEp rieqha ����� 1F 8 CU155
UCENSEp CpNTRACTORS DECIARATION rnSiRi[r vRocf55ED Br -�
I hereby affirm thar I am licensed urder powairn�aof•ChoPter 9 �SrSt�ht WTtETs � . � I
�rnmmerrcing with Sec�ion 7f%701 of Divisipn 3 of the8usineu oU71Ei50VER . y �
and vrofess�o�s c.ode,and+r�y i�ceme q�n ruu taco ar�deisea. s�c s.s�nn FINAL � VALIDATIGN � :
. . ' DATE '1 V I
Lkense Numbar ?+���4:�ic.Clau�_ . �
Env. Eng. oare 7"2§"$5 °'� ev"^i �
Conho[Mr I
W i
� I am exempt undar Sec � . . . , ' d �
�? 8.8P.C.}a�hn reoson � N '
Plan check fee � '
' Date: p�UµgING PERMIT I$$UING FEE S IO �Q► . .
� Signafura �
iOTAI fEE � -�� /Z..'`.�
� - Plan[heck opplitonl �n • e o •,rj i
SINGLE FAMIIY �
� HOME OWNER-BUILDER DECIARATION Name �- - . I • :�O J G
I heroby affirm�ihaf I am exempt from the CaMroNor's license qddress
low in.�6e followirtg reaeor.(Sec�ior.?031.5.Bosir.ess ond . . . . . a �.�J�+�
Professions�oda): - Ciiy Tel.No.
❑ I,os owner of the property,will do tha work and the � �7�O—�j� .
shudure is no�intended or offered fer sale(Secrion , .
7044,Buainese ond Rofessiom Code). ' � _ � �
CANS7RUCTION IENDING AGENCY . . - � �
I hereby a!lirm Ihot Ihero is o conshuctian lending agency for �
the perfamance of tha work for which fhis permit is iasued . � � . � '
(Sac.3097,Civ.C.�.
(
Lender's Nome � .. � ��i
3
Lender's Address
I certify�Fw�I have read this application ood staie ihot rhe , . � � i
above informotion is carecL I agrae to comply with all Ca�n�y
ordinanc on 9a�e lows regulo��nq Plumbing,and hereby • - !
aothori pr lives of this COunty to enler upon Ihe . � � ' . �
above- e fion operty f inspection purposas: �
s n� SEE REVERSE FOR EXPLANA70RY LANGUAGE , •
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Signolure of Permillee D 1 - - - �
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