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F j!��'��� �WORKERS?COMPENSATIONkDEClARA710 k����,;,�;� 54'��' i>� � � $ � �'^� � �'
� =z,; � ��< �,�����������4P;P�L��°AT10� '��0� PLU.MB�NG��PERMIT� �. � ��� 3� ��
„�_��herebyt.affirm ihat I have a cerriNcate of consent�ro sel{`',w76.n667n���� }�- p �.� ��; g4 a a. '
ns�e or a ce���ficate of Workers'Compensq7ion Insu�ance� � iCE 817(REV 10�8L) �f . • ; }� t p � � �' � � t °
� ��or a certified co thereof Sec.380Q Lab.G i .�. ' (� � � � � ' � �"�"fr�'k"ki�d�l�t ""��' !
� py ( � : y , �s�F CbUNTY'OF LOS;ANGECE55 , � BUILDING I1ND'SAFETY �eo�y,rLt�.`�,���a a ,` t z •`�;;
� ��Y N�/N0507528�onipony Farmers =� , � �,
� Cenified co is hereb furnished. �� t,y�;
�� �'❑ PY Y ��+�� FORAPPIICANTTOFILLIN(PRINTORTYPE) /�ODRESS 1405 S. Stonecrest P a r�� ���'
y Certified copy is filed with ihe county building nspec 7; ,? �
�ion de arlmenf. NUMBER FIXTURE OR ITEM (t� fEE S��
g ,s p •�. . LOCALITY �
��'� � WATERCLOSET � � Diamond Bar y "#y
1 �i ;oare 7/2/SS Applicant P:�.O_ Pl ,mh,ng_,:� NenResr � �n
a CERTIfICATE OF EXEMPTION FROM WORKERS � BATHTUB �� � CROS55T. � � ��,
�'� �� . COMPENSATION INSURANCE F= �/ SHOWER OWNER gramalea Limited "-�� -'��
� _.(This section�need not be complefed ff fha work involved by;' MAIL t��' ��'
�
-:the permit is for one hundred dollars(5100)or less) �¢�+ LAVATORY � �qDDRE55 3151 Airwa � Ave. Ste, N * q�
7j 'I certify that in the performance of tHe work for which this -
�+ SINK CITY iEl.NO.
} ..permit is issoed,I sholl not employ dny person in any manner�� W Co.sta Mesa 8Jr0—1��1
��so as fo become subjeU to the Workers'Compensat on La 5 2�'».� �
� 4� � DISHWASHF.R k �.Y ",�
�� en'7 COMRACTOR P,R.O. Plumbing
��' ^,.i. !l
�':Dote Applicqnf r CLOTHES�YASHER � '�v qD�RE55 4418 �'', Chapman r j', i
x ?.NnTICE TO APPLICANT: �f, ofler making this Certrfcate of j'',�'
F ' �'� SWIMMINGGOOLRECEPTOR
s "t.np�ion, you should�:become subject to the Wo ke s '�` CiTv TEL ta0. r
�
5 ,a, -iipensqfion provisions.-of the Lobor Coc1e;you musl forih 5,,�� �AWNSPRINKLERSVSTEM Orange . 630-8441 �
�}with comply �h such provisions or ihis permit shall be, x�!" STATE LIC.
� �;deemed�e�oked. , �'� WATER HEATER � uceNse n,o. 443774 anss C-36
� `� � LICENSED CONTRACTORS DECIARATION .�^ � oiSieiCi NO. PeOCesseo eV ���:
� � xl hereby affirm Ihat I am licensed under provisions of Chapter 9��Vx GAS SYS7EM OUTtE7S � --: '
�4�e+ �.(commencing,wifh$ection 7000)of Division 3 of ihe B�smess' '4 OUTIETS OVER G . g.�;`�
� '�'mand Professions Code,and my Iicense is in full force and effect �a�' S vER SYSiEM PINAL V IDATION �""','s
( ��{ DATE /S'�D/d'� C�,t.
�' .�License Number 443774 Lic.G`(ass r—�F+ � �?'
i � � ��� �
��� FINAL � �..`.:
I 'ContradorP_R_n_ Plnmhino Date�_?T�$� �,r�� BY '�'`��v �� �
�-.
' �f�'❑ I am exempt under Sec. �7x? �g..�.';
� � k ti.�'��, rii;. �
� B.&P.C.for this reason �""�; P�an check fee � + ���
I _� ' Dafe: ��'y�'. PWMBING PERMIT ISSUING fEE$ � ,�(% 'r�
�'� � Signature
�
�'�� .�,, �y�a' TOTAI FEE tS� .� 3 Lr r a '
X u�.�� Plan check opplicont ;y a
� ��� S!MGLE FRNILY �j
� HOME OWNER-BUIIDER DECLARATION '^�:lName � j � , C�q f:(� ����
'� ' 'ieby affirm that I am exempt from the Contr�ctor s Lice se��'��
� yior ine ioiiuwir�iy reason(Sec iun i�o��, us .;��'���Address @ 4y ^� v i;�
�; � ,�f P�fessions Codep ^^ o �� , City Tel.No. .
� 7 I,a s o w n e r o t t h e p r o p e r t y,w i l i d o t h e w o r k a n d t h e�, � � !, I C'�:5 �
�'�.'�11� structure is not intended ar affered far sale(Secl�on�t���' � � '
i�`d �7044,Business ond Professions Code). ?aj'�,"t�f€��;� � ,
�a�� CONSTRUCTION LENDING AGENCY ��:5°�.� t �'k��'
�. �'I hereby affirm that fhere is a mnslruttion lending agancy for'�:�,; , ' � �"��
r .;�.�the performance of the work for whic6 ihis permir is issued';,�,�� � �
� �,�(Sec.3097,Civ.C.):� " '�.; . - y
e . �;�.; :
�ti Lender's Name ,���'' :t �
t t:i ��s:
� -� Lender s Address .�.!
� �I certify ihai I have read this application ond stote ihot the��:+�.- ► i
� .:!above informotion is correcl.I agree ro comply with all Couniy.3'�� � -,'
^'�ardinances and Stale laws regulating Plumbing,ond he eby,,�> � , ���
I s 1Eaothorize represenratives of ihis County to enter po ihea�; . -
� �above�memioned property for'nspect on purposes. Y�jw-:
� 0,r 1 r �� � � SEE REVERSE FOR EXPLANATORY LANGUAGE
/fi1s.
� �•� ,�' P'r
� ign ure of Permittee D e "�'�
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