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wo�Rs•coM�u,T�oN o��aAnoN APPLICATION FOR PLUMBING PERMIT '
I hereby aff�rm�hof I hova o carrificate�of coment�o salf lyqyyq � �
insure,or o certifiwte of W'orkeri Companaation Imurance, Cp BII�REV.lOiBi) � ;
or a ce.ritied copy�hereot($�c.3800,tob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Q�v�.$5�)1�89�ompo�y�i'remc�nY_ Tndetmi�3r . ;
Certified copy is heCeby furnished. B�G I
� • iOR AV7lICAM TO FIU IN�PRIM OR TYGE) A� O '
Certifled topy ie filed with the caunty h�ildi inspet- � F���� � �
non dapanmenr. �ocA{nr Diamond Bar
Dote �+�„�j�.�S_erplisanr • wATER CtOSET J � �
�RTIFlCATE OF E7SEMp�IOt�f Fl2pM YJORKERS� aA�rug � , c`��ss si 60/Phil l i s Ranch i
COMPENSATIONINSURANCE SHOWFR � SOl1tIt CO1111tT CbY' . �
(Thls ncllon n��d rrof he mmpleted f1 th�work�mrolrod 6y , . }
th�p�rmttls foe ans hundnd dollan(S10D)or Ins.) � �qyqrppy �� i
I�enify�Fwf in�he performonSa ot ihe work for which rl��� , �
permie is issved.1 shall rw�employ any person in a�ry manner � SMK crtY �El. �
ao as ro berome s�bject to the Wqrkeri Compenwtion tawa. �
oisr'w'u"ER `' �"�R.C:R. Plumbin INc. ;
Dute �pplimm � C10tHE5 wASMER � .� � ,
NOTICF Tp APRICRNT: If, qher mpking�hia Cer�Ificafe af �� �.2785 �2. 0113 �1V2.
SWIMMING POOL RE�PfOR ,
� lcmption, you shoUld bacome subjed ro tha Worksrs . - _ ,
6mpeneorie�pro�biom oi�he Lobo.Code,yw m�s�fonh- cm . tEL N0. •i
with comply with suth pronsiona or Ihis permi�shall b0 ����R SvStEM •
deemedrevoketl, yyp��p� n"' nio. 36428 �u C-36
IICENSEO COMTRACTQRS DEGtJlRAT10N oi5nticr rao. rRoctSSEo er
I here offirm tFqf I om licansad undx �5�� �� y ;
by prrnisiotqotCAaptx9 .i0
(commerrcing wiih Seaion 7pDp1 of Dirieion 3 of the B�ainess p��TSpyEp d ,
ard Vrofessiom Cflde,prd my liteme ia in fidifprce m�d efieA. 5 oER SYSTFM ftNA► �
� DAiE ���`l�S5 V LIDATION o ;
limnse Numbn ��,4=8 �,�.ci��.3,y__
� �
ca„�,��b. RCR Pltmibixtgoare 6/19/: ev� � ;
❑ �om oxemp�undm 6ec. d :
N '
8.8P.C.(or thi�rcason � ? i
Plan check fee
�e� PLUMBING PERMIT�SSUIIV�fEE S 0 6 �1 7 7.1 A '
SigncNrc i
fOTAt FEE 1'f! ��\ �+
1[p v #. . . •.5
- Plan check opplimnt
SINGIE FAMIIY ;
HOMF OWNER-Bt1IL0ER OECIARAT1pN Name a • . �� • •7 Q 5 O I
/ ppp���ebY affirm tlw�I om e■empl hom the Conhac�o.'s licenas �� . � ♦ . •7�rJ O� �
, ,Iv for the following reoeon�SeUion 7031.5,8vsinem a*d `
� Frrofeuions Code?: ���y Tel.N ��2 9 a g Jr �
� I,m owner of�he propery,will do the�work orn!�he '
snuaure��no��ntended w offered fw wle (Section ► 3
7fM4,Business and Profesaiom Code). ' �
CONSTRUCTION IENDING AGENCY
I hereby affirm the�Mere is o rnnsnuc�ion lending ogerxy fw ,
the porfprmance of the work fp which Ihif permit is issUed 1�'
(Set.3097,Civ.C.). . �
LendM'a Nome
{
Lender i Address �
I cemfy+hcf I hore read thfe oppliccrion am1 atate thot�he � �
abore informatian iy conect.I vgrea W comply wi�h all Co�nfy � �
ordinonces ond State laws.egulatirg Plumbing,and i�ereby
authoriie representotires of th�s County to enter upon rha
above-mention oper f r in clion purposea. j
�nJ��\ 4t�'���� SEE REVERSE FOR EXPLANATORY LANGUAGE
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