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HomeMy WebLinkAbout1134A (5) "RS'COMPENSATIONDECtARATiON � APPLICATION F4R PLUMBING PERMIT c�� � �+I bave o certifimle of conseM fo self 76A887A ' - ,oi Worke�s'Compenso�ion Insurance, CE 817(REV.8l88) � � ,��1._� .�areoi(See.3800,lab.C.) - . ,9 H��,�nds Insurance ���COUNTY OF LOS ANOELES DEPT. OF PUBLIC WORKS . i�'= ;mpy is heroby furnished. � BUnDING - s' fOR APPIKANT TO Flll IN(PRINT OR TYPE) 5�%5 ied copy is fi����v��t�qy�g�jq��-In nooR�ss 22910 Estroil Dr. . ,������ NUMBER FIMURE OR ITEM � FEE ' e 1OC'"'T'` Diamond Bar ApPiiGant ].8 WAlE4Cl06ET 6. 10 00 NEAREST porto Grande/Montefino CERTIFICATE OF EXEMVTION FROM WORKERS' 14 BATHNB . 6. $4 QQ ca0655T. ' � COMPENSATIONINSURANCE� � 6 s�ow�R 6.� 36 00 OWNER Presley of So. Cal .�(Thi���ct�on nNd irot M compl�t�d ii�h�wo�lc fnwlwd by ,y�p�� �h�p�rmif Is fer ono hund�dollan(3100)or I�t�.) 2l� lAVATORY E). 14 00 nowtEss 17791 Mitchell South � I certify thot in the performonce oF fhe work for wl+ich this Irvine , - : --- permif is isl�ed,I ShO�I nol employ ony penon in ony monner SINK • CITV iEl.NO. _ �• so os�o become subject�o Ihe Workers'Compe�sotion laws. Di5F1wn9iER \ 6 6. 3 00 caa�croR P umbin In f \,, aPPt�co�� 6 CLOTHESWASHER OO �Ess 127 W. State St. ..ATICE TO ADMICANT: If, aHer making this Certifitate of SWIMMINGVOOLRECEPTOR � -�mption, you should bemme subjetl to the Workers' ��TY Ontario, CA iE�•�86-5878 � �c 'j�pensotion provisions o(Ihe Lo6or Code,you must for�h- �qWNSPRINKIERSYSTEM ; h tomply with suth provisions or �hiz permi� sholl be ��"Ns�,,a. 355068 CL45S C-36 dRemed revoked. WATFR MEATER IICENSED CONTRAC10R5 DECLARATION' � DiSiRiCt np. PROCESSED Bv GASSYS7EM WTLETS yy� I hneby affirm thor I om licensed under provislons of Chapier 9 6 6. 36 �� �' \• 10.\O f� �'� (commencing wi�h Sedion 70�)of Division 3 of ihe Business 6 OUTtFT50VER 1. 9 00 d o�d Professions Code,ond my license fs in iull forte ond effe[f. 5 PER SYSTEM FINAL � YALIDATION �' DATE U� �icense Number 35SOGS ���,Class C-36 Oc ; �lmatore Plumbing. ��c. 8/26/87 B�� o onvoc,or o e c.1 i W ; � I om exempl unde�Sea � � . � y � "1 1 a.tA z B.BP.C.for this reown P�Q�CF7BCIC f@e - , � � �+e . . . .5 � — ' Date: � . . PLUMBING PERMIT ISSUING FEE S � ZO SO � •j'J�,j Q � Signoture ' TOTAL FEE S�II SO . e �.�';•']�.Jr Q u ' i—�-- Plan check opplicoet . 0����8 7 . SINGLE FAMILY ��� ) HOME OWNER•BUILDER DECL4RATION Name � _ � ' . :�-I f+..eby oH�.m thnr 1��+e•emne fmm thw Commctor's license . . . , �for the foliowing reason(Seciion 7031.5,Bueinese ond �ress . �esaions CodeJ: City Tel.No. . . ❑ I,os owner of the propx�y,will do 1he work ond tfie � ., slrudure ia not in�ended or oHered tw wla(Section - - - � � � - - � � - � � � � 70d4,B�siness and Professions Code). ' CON5IRUCTION LENDING AGENCY - �� � - - � � , 1 here6y affirm�hat�here ia a construction lending agency for ' rhe performonce of the work fa which�his permit is issuad � � - � (Sec 3097.Civ.C.). � ... . i tender's Nome � , , landx's Address � . I terli{y that I have read this appGcotion end sta�e that the - , - � � -- - � obove infamotion is correct.I agrea to compiy with oll County ordinances ond S�ate lows reguloting Plumbing,and hereby . . . . . . � � - � oufhoriz representalives of this Cou��y�a enter upon Ihe � abov en' ned p erty for inspetlion purposes. � SEE REVERSE FOR EXPIANATORY LANGUAGE � G� �� Siqnat r of P inee Da�e_ � . 1 ' ' '_ . " • �• , . •- C Gl " S Gl � x� C D[ ,' - T C O L �. O � �� j� = N i (n N C: O m V� ' { C; S G n � � . . I ' . j ;"-'.I_.�1 vi ` � �IT� � 7 T r T ; I ;,. , �, �, c> � • 1 ' J� 1 i�l• , r� � ~ � y (' �� �' < U I 1 �..J I I r .. , i I !. � 2::�. I r^:� '�T. 3• ;� '= O � '- ( , � - . ; .. I.` ' . ',. i !i i i j � U d,�, xi �i " � N � . � '� �` c'. ,i' I C� i �~>j; � 'I .I I 'I •� ` .. � N . . - � i(; _ , . ! _� - .i�.: i �i: - , . . � I � - , .. I i �r• �- � ;1.. i:.j e_ v; m ; i. , ' I•{ 1 �I" , �I ;�� 'I^ :-I l.l � I � �� '� ��� i !•'{ ; � F- I , � , �-� �' � i` 4�' I �: _\\m . . 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