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i � r•ti.JRKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBIMG PERMIT $� -sleby,of(frm thai I hove a certificote of consent to self 76A687A- . 4. � .�nsure,or a cerlifica�e of Wo�kers'Compensafion Insurance, CE 817(REV.8/88) •- � - - � �.J � � � � `or o cer�iffed copy theieoi�Sec.3800,Lob.C.) � � � � ' - � ' Q�C�§05739 Hi�hm � ds Insurance Co: COUNTY OF LOS ANQELES OEPT. AF,pU�LIC..WORKS � r �� Onits 401;402,403.404 ,405,406 Certified copy is hereby fumished. - � ' ' FOR APP�ICANT TO Fllt IN(VRINT pR TVP[) BUILqNG , . Cenified copy is filed with fhe taunty b�ilding inspec• App�S 22916 Estoril Drive �io�deparfinent.- NUMBER FI7CTURE OR ITEM @� FfE , % 8/26/87 � ore Plumbin , LOC""�' Diamond Bar ; oo+e p �n� q 18 WATERQOSFT 108 00 NEAREST porto Grande, Montefino CERtIFICATE OF EXEMPTION FRpM WORKERS' eATH 7uB � � 0� ��Si� �� � � � COMPENSATION INSURANCE 36 OO OwNER - � (Th��a�clian mad not b�complNsd tf 1h�work inrelr�d by 6 SNOwER � �. fh�p�rml�it for ona hundnd dollen(=100)or I�ss.) 24 �nvnroar . 144 00 �"�� 17991 Mitchell South � ��eri�fy thor in ihe performance ot�he wor4 fw which thiz permu is issued,I shall not employ ony pereon in any monner ( �� 36 0� ��TY Irvine � TE�-NO�660-0660 . ., so os�o become subjecl io the Wakers'Compensotion Laws. 6 DISHWASHER 36 �� GONfRACiqt � ' ` Amatore Plumbin Inc. , �� n�i��o�, CLOTHESWASNER a�Eu 127 W. State St. ��� '7.T0 AVVLICAN7: I(, after moking this Certificote of SWIMMINGPOOLRECEPiOR � m, you should become subjed,to the Workers' � wtion pov�stons of the lobor Code,you must forlh• ��TM Ontario � TE�.No.9g6-5878 . �r, LAWN SPR7NKlER SYS7EM mply wi�h such provisions or �his permif shall be - STATE IIC. ��� j revoked. WATERNEA7ER ' 36 00 ���N�"1O' 355068 �� C-36 °� -UCENSED CONTRACTORS DKLARATION � D�STNiCT NO. vROCE55ED BV . 'e )y oHilm flq�I am IiCGn�U�9I Pr0��5�0�5 Of C�10pIN 9 6 �SVSTFM WRETS 36 00 �.` /y1 � � . "� �encing wi�h Section 7000)of D�vislon 3 of the Busi�ass WTlfT50YER , �J �` �a O Y rolesson5 Code,ond my license is in foll force and effecl. 5 VE4 SYSTEM FINAL � VALIDATION d ��se Num6er 355068 �.�.�lou C-3G . DAT U �matore Plumbing, Inc.8/26/87 BY'u o �nuc�or onre . . U � 0.� I am ezempt under Sa[. t, 1 �5� � B.dV.C.for this reawn plan check fea - � - � Z - oo�e: �� , � s s .�j . � � MUMBING PERMIT ISSUING FEE S 1Q rjQ I •5 5 9,5 0 s�y�awro TOTAL FEE • 'r:i 9,5 0=� � � . Vlon check appl�cani Q f�2�..8 7 , ;� �� SINGIE FAM7LY . ��•� . HOME OWNER-BUILDER DECLARATION Nome _ �I�?reby oflirm�hol I am exempt(rom�he Conhac�or i License . � . �fvr�he fo!!o:�ing;scson(P,e-ciion:031.5,Susiness and Addrees - - - � � �essiona Loda): City Tel.No. ' ' ❑ I,as owner of rFe properry,wtll do rhe work ond t6e � siruc�ure is not intended or offerod fo�wle(Section � � -- - , - 7044,Business ond Professions Code). � CONSTRUCTION LENDING AGENCV � " �- � � � � � �-- � � I hereby offirm rhat there is a conshudion lending ogency for - the perfo�mante of the work lor which this permi�la issued - � , - - . " '- ' - � (Sec.3097.Civ.C.). lendar's Nome � � � lender i Address � I ter�ify�ha1 I have read�his opplico�ion and stote�hat the - � ► , obove inlormaiion is corrocr.I ogree to comply wirh oll Couny - . ordcnonces ond Sfote lows regulating Plumbing,and hereby . . ... . � . _ oothmize pre: nfativ�of Ihis Coonly io enter upon 1he obov mion pro Iy for inspecrion purposas. SEE REVERSE FOR EXPLANATORY LANGUAGE O L.� � S�grwtur Permiuee Daie � . _ � � F' C C � � U N U� C' r^ . G �l � JJ . Z � � `� j � � l� • � '�Z T � -1 � •� ^ ,n �N v _f n r, � �7 `-' ii �G d 0 . �;-� ' ° ' � ". 1 �i "' � M� I .9 �_`F '�I � ' � J. �l.,7. . � � i. . i'. � . � � i � • p'�1 � _. 1 4; � � � � l. ., ` ' ; C: s'1_. � '� � . � •� i ; 1 � v i .��., �,:.� �1- � '. � �. 1 ;�I �. i�` _ 1 � � 1- 1��' ' l 1� ''1 `,l.• ��t c� - � � � ' .. ; � � , '.,`. . `, '',i. � -1 ^. �I.' ;�m .. : _. 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