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1132A (5)
. WORKERS'COMPENSATION DKIARATION - � �ppLICATION FOR PLUMBING PERMIT �\�� � I hereby,offirm lhat I have a certi{icale of consenl fa self �gpgg7p _ , . � 'insurc,or a certificote of Wor4ers'Compensotion Insuronce, CE B17(REK 8/8B) � " or o ceni(ied copy thereof(Set.3800,lob.C.) - - � . . �� f�5739 Hi dS insurance Co. COUNTY OF LOS ANGELES DEPT:QF pLBUC WORKS O�'y �I�� Units 433,434,�35 ' Certified copy is hereby furnished. y�i�� FOR APPLICAM TO FILI IN(PRINT OR TVPE) ,�REu 22915 Estoii 1 .- - �� Certified copy is filed wirh ihe coun�y building inspet- .NUMBER FIXTURE OR ITEM � FEE �- • S/2����°"t�matore Plumbing, Inc. wnrEeaos�r LOCAL�Y Diamond Bar' Dote Applitant NEAREST , � . � CERTIFICATE Of EXEMPTION FROM WORKERS' � 6 BATH TUB �� (. 36 QQ �'�ST• Porto Grande M II ' - COMPENSATION INSURANCE ��R OWNER Presley of Southern Calif rnia (Thl���dlon nwd not M eomplN�d li fh�work involr�d bY 'N'0'�� 17791 Mitchell $OIIth th�parmlt it for om hundnd dellan(5100)or Ins.) 12 �AVATORY 6. 72 00 n�urs�ss � I certify thot In the parformance af ihe work for which thls permil is itsuld,I shall no1 employ any peraon in ony monner� 3 S�NK 6. 18 �� ��TY Irvine � 'H�NO� 660-066 ._ \ eo as�o become subjecl to the Wakers'Compease�ion lows. 3 DISHWASHER � 6. 1a �� �pp17R,4C7OR . , `te o IicoM �� 3 CLOTNESWASHER 6. 18 �0 �matOl' P umbin � Inc. � PP ADDRE55 127 W. State $t. . _ -. ..OTICE TO APMICANT:,If, aher makiny �b�s Ce�liiicate of SWIMMiNGP00LRECEPTOR ' �-emption, you should become subject to �he Workars' ��TV Ontario �����986-5878 . � }�pe�sa�ion provisiom of fhe Loba Code,you mus�forlh- tAWNSPRiNKlERSYSTEM .�h comply with sVtk provisions or this permil sholl be - STATE IIC. deemed re�oked. 3 WA7ER HEATER 6. 18 00 ���"� 355068 awss C-36 � UCFNSED CONTRACTORS DECLARATION ' DISTRICT ri0. iROCESSED Br GAS SYSTEM OUi1fT5 I hereby affirm that I om G�ensed vnder(xovisions of Chaptet 9 3 6. $ > (cor„rr�enc�ng wt�h Sece�on 70W)of D��hcon 3 oF+he Bueine�s 3 WTLEi50VER � 1. ,4 r�0 a �n � a ond P�oiessions Code,ond my licence is in full imce and effecL 5 aER SrSTE�n FINAL VALIDATION �- DATE V; litense Number 355068 �;� ebss C-36 a; �m�atore Pltunbing, �n�c. 8/26/87 gYA V ❑ I om exempt under Sec. y 8.8P.C.for li�is reason Plan check fee 10 50 , `?1 , �2 k = �1e� 7lUMB�NG PERMIT ISSUING FEE S � �E � e e s e� $iynofure � •2 8 a b 0 TOTAL FEE � . Plon cbec4 oppiicon� ... e e��S 5,U Q� ' � SIIVGLE FAMILY . . . .. .__ . HOAAE OWNER-BUILDER�ECIARAT�ON Nome ��2��8'] ��'��I he�eby aNirm fhot I em eYempt from the Contractor's License . . . � � - � � �- (for.�he ioiicHing reason($ec��on 7031.5,ousiness and A`i`{�a"s _,Feesions Code): �� . City Tel.No. � ... � - ❑ I,os owner of�he properly,will do the work and fhe structwe is no�intended or offered fa wle (Settion � � - � - - • � , �'� - 70d4,Business and Profassions Code). � CONSTRUCTION LENDING AGENCY � � - � � . I he�eby affi�m�hol fhe�e is o consrrudion lending ageocy for . - ihe performonce of the work iw which rhis permit is iswed � � � � - � (Sec.3097.Civ.C.). - . Lender's Nome lender's Address � �cenify�hot I have read this opplication ond stote iho�ihe � � - , � � � , above in(ormo6on is careU.I o9ree ro comply wi�h all Counry � ordinances and Srate laws regulating Plumbing,and hereby � - _ � ' auihori e rep�esenlaY s oi this Cauniy to eMer upon�he abov men i ned p riy for inapeclion purposes. / SEE REVERSE FOR E7(PLANATORY LANGUAGE Signotu of Pe ittee ��e/ � . � . .. ,.. . . .. . . :=7 C Gl ^ - Gl � r. C �,p Z =' Y C y Y D O Z �„� j. ��v+ v+ v. c: v , n,�' ' j' ci < �o G7 F _ . , �_ ..i;_.__ ..�, n �� T � -; � `� -- i ' . � T y � i U �1 }l �1 �. � D ,� � C) ` j .. R ;- c' i.. ' � � ' y!'=� � `� � 1' €� �� o .. _ I= �,�, _�c:, ' .j� I 1�: �S. �^ �' 4' ' `^ ~, :_ ;• ,.�-� ; c � `� � '�; I•. � ; � �. : � .. � „ �_, � �� j r � '`� �.' 'I• -iQ�(� ` .. � � -- _� -_ � , j . .� ! i �� �� ! F�wY'(, •,/ . � . . --_ . . .� ; ,� , � ��� . . o ;:_ � ; ��_. � �._ �:� ��►T . . � : v�'+ , - � � ; i;.� � ��: .I,:. , ; � . 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