HomeMy WebLinkAbout1610A .,=4..,� -� ;, .,..,_ ,r, �-,. ,.�.--. ., - _.� ____ __- _ _ - �, ,.:;.a �, . ._ � - � � WORKERs-�o^^PENSAT�oNOE��ARAT�oN APPLICATION FOR PLUMBING PERMIT � I hereby�affirm that I hove a certificote of mnseN to self 76A66�A ' � � ,''� insure,or o.certificate of Workers'Compensati6n Insurance, CE 8rZlREv.70l87) --- -- - - ------ � -� -- -- � - � .. ��� � or o certified copy�fiereof(Sec.3800,L�b.C.) . COUNTY OF LOS ANGELES BUICD 2NG AND.SAFETY Policy.No. 5084266 comPa�y Gr Amer:ican - - � �.. � � t� � '.- /.;,�c.,?�':' .��' � Certified copy.is.hareby furnished. � � . . - - eUI�DING �� -�� � � ;' � � � FORAPPLICANTTOFILLIN(PRINTORTYPE� � ADL�RE55 3543 HaWICWdOa Rd. -� Ceriified copy is filed with ihecountg buildang inspec- NUMBER FI%TUREOR.ITEM -(� FEE r�on depa�rme�v �ocauTv Diamond Bar. � � �WATER CLOSET . � /' � �- �' - Date - �-14-R4 Applicont Taazvar�Fn'n � NEAREST � � �'y r CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' ��.c gATH T�8 � �� _ �� � '^� . � v�.. COMPENSATION MSURANCE � � �- � OWNER --� ` .-- - . n, "- � SHOWER - �. . _ (This ssc�iaR need nol be compleT�ed ifi the work involved�6y . �-�- MA�� 20$Z-BllS1ri2SS C."8rit@Y DY.�- the.perm7-is for-one hundred dollaro(f100)or less.) tAvaTORY - . ..�- '"' AooRESS _ _ I cartify that in ihe performance of!he work for which this SiNK � - � � j�� pBrm�itisissued,.4shall-notemployanypersort-inany'monner � � �'� '� ��TY . ��I�Y"V1112 � }Z']].¢ TEL N0.�33-Zi�� .. �`� sa a5 b.become su6ject to.fhe�Woikers'Compensation Lows, f DISHWASHER� - � � ' i-, COMRACTOR ' ' ''� Da�e � �Applicanf � ' CLOTHES WASHER ' - eG � AD�RE55 � �:� - P �E-TO�APPLIfkNT:-It/-pftet tnaking this'Cerfifimte of- � SWIMMWGPOOLRECEPTOR : � - �f ptwn,�you�should become iubject to ihe Workers: � CI7Y jryl7tiP.� 92714 TEL n,o.. g�3-1160 . �Compensation provisions of ihe Lobor Code,you mustforih- �AWNSPRINKLERSYSTEM � . � with comply with�such.provisions�or fhis permif shall be . STATE � . . LIC.� ... . . deemed�eJoked, °. � � - � WATER HEATER , /� ;.- �KENSE NO )]_ (9 C1A55 � 3 ��': -� �LICENSEp CONTRACTORS.DECLARATION � � � � �37 DISTRICT NO. P OCE55ED BY. ' I hereby offirm ihat 6om licansed under provisions of Chap�er 9 �GAS SY4TFM� �� OUTLETS - �; .:-^ ��j ���f � � � . (ommencing with Section 7000)�of Division 3�of ihe Business ( . OUTLEi50VER� � _ g ' Z' r� - S PER SYSTEM. � � ❑nd Professions Code,and my license Is in tull fo�ce and effect. FDI�N EL ��� f�� V/��}D{�T�ON � � i; � � t License Number 191969 � uc.Closs �'�ti� - � ,q � � � . . . . � - . FINAL / � . � ' Leaverton' 2-13-84 Bv ('J�ia-� /�""'' Coniractor Dafe . � . . 6.. - . ❑ . . _ . . . . . . . . . ._ .. . _ � ' � � . � �. -�.I am exempl.under�Sec. � -�- :�, ;- B.BP.C.for ihis�eason . . - - . - � � ► � . �� �" Plan check#ee . Dote: �PLUMBING PERMIT ISSUING FEE$� � �!)� ���-� � � � . - �'� ��`��A - SignaNre .. _ . � . . . . � ,�:� . . �c o-o a m? - TOTAL FEE � - . . � � Plon che[k applimnt � � . ��`�' a�9�•`�:�. . � -SINGLE FAMILY � - - � - . � -�� � � - � �� HOME OWNER-BUILDER DECLARATION Npme � -- � � � � " � � � � � ° � ^�i�,S:;��� . � � ' �by offirai that.l am-exempl-{rom ihe Gontroerors License� - Address� � �� � � � � � � �`.' '�.'j�8 t{ ��� L�... for the following reason(Section 7031.5, Bvsi.ness and _ _ � � � - P�ofessions Code)f. - � . � City . � Tel.No. � . ❑�.I,os o ner of tRe property,will do the work and the . _ � � � �. � . sirucN e.is not�irnended or offered for.sale (Setlion . _ � __ .. --- -- .�--,� - -. - . � � � � ._ ..._ ._ ... _.. ;. 7044,BJsiness and Professions Code). � � � . CONSTRUCTION LENDING AGENCY� . � � -- - � � � � � � � :. ._ - - � - -��- � � - - - . _ ' I hereby affirm Ihat�heFe is�a consiruction lending agency for . � - _ - � - fhe performance of the work for which(his permit is issued . � � . . � � - (Sec.3097,Civ.C.). � � �. - � � - Lender's Name . . . . � . . � . � . ' � .. . . . - - Lender's Address. .. � � � . ... . . . . . . .. .- .... . . . . �� � � ::. I e nfy that I hdve read this applimtion and stale th�t the . . . � .. . . ��� - . . . . � - - . . . . above infarma�ion is carred.I agree to wmply with oll County . � - a dina es and.State la,vs regulating Plum6ing,.and hereby - � . � . . - . aulhor'k repre n atives of�ihls Co nty ro enter upon the � � � - . . . � � � abov 5»ention operty q nspecfion purposes. - - . . � 7� �`� SEE REVERSE POR EXPLANATORY IANGUAGE � . ,�-��-� �/3_ � Signature of Permlflee Date� � � , - . . �- �� - � � _ - � - . �, . �',��o �1 � a ���''�� � � �, a �,�'� � �ti���� ��,� ; t �n, �� ��Z G ra '�so Z a , ��3 S� �"� U��a,���y.. � � i�P 1L O, - �. F a � �O � yn `�'� ���, � � � Z � v � , , O� � �O �� � � y` �}7 ... - . � . . � - , . . .. ��,.. 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