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HomeMy WebLinkAbout1299A (6) ..� -� :'�y?� .��.�':�L;.\�,�.,�.",^T4,��Rw.,...;"si„-.-�,-;�. ;:�,s.a�c.:��.��1�'aw� �'��.�:'� �`� .:�".t;�`*"'�F�:"r.t��{i�n-�:��`.`�r�� ..b -. .h`�x���E.M li'���.,fi f�` �;�..,: n -� � ;.`. i x�a ��� �� y� �� � a � .:;� � : b� {� s �� ti i� � w 4 �;����:�s WORKERS.;�COMPENSATION'�`DECLARATION �3,` � �5.,;�;��, �. � { r � �, j�� � �� ,�� �����ARP:��CAT.10< F� P�U:M'�BING�PERM'IT � � , �,�.� , �,, �, ,_I,.herebya�affirm thal I have o certficote of consent�yfo self�M ,76q��pj��_,��"�r ' � :� � �T�.,��r� �, : ,� .r insure,or a cerfifica�e of Workers"Compensation Insuronce{ CE 817(REV IU✓8Ir :• � ? ; , 4:� � �,y,"1���,��P= +y.�g �c y '�'or a cert fied copy thereof�Sec 380D,�ab.C.) �t° �' °; ,��: COUNTY:OF LOS ANGELES � ��. � BUILDING AIQD SAFETY ��•'t a� a¢;ri�w �� a �tt �:,- .;t .' � �,' . ..�>�.,+ . . * . , .: . �,,..oY:::.���`�'.�M�`�¢�.,� Ea t�:�;, ='��y,No.N05"07528�o,,,pp„yFarmers � S , i,� � �; Certified copy is hereby furnished. .��� BURoitvG P`�A '��' � A� fORAPPLICANTTOFILLIN(PRINTORTYPEJ qpDRESS 1409 S. Stonecrest Place �y �.�'�, .� Certified capy is filed with the'coonty building i spec ± fiondeparfinent. ��'��' NUMBER f1X7l1REORITEM C� FEE �OCALIiV ���+ '�; ,' /(� Diamond Bar �, � k �.Date 7IZIHS Applicant P R O P1��nP �� WATERCLOSF.T A(I PJ�� NEAREST � �.�-: � BATH TU8 / CRO55 ST. n� ..�'e�.� '�'� CERTIFICATE�OF EXEMPTION FROM WORKERS �i�� t :� COMPENSATION INSURANCE 4"�p OWNER s� ����� �cs SHOWER Bramalea Limited ��(This seatlon need nof 6e compleTed if the work involved by � ��� ��f ;F S��,S ''the permif is for one hundred dolluro(5100)o�ie:s) LAVATORY � � aooaess 3151 Airwa Ave. S�te. N y��. � �I certify that,in the performance o4 the work for which ihis'2� .. ;-,;permd is issued,I shall no�employ any person in ony manner�,^ SMK (j77 CITY Costa Mesa 'E`."o. g50-1001 d'�.��. �+so as to betome subjetl to ihe Workers'Compensafro Laws DISHWASHER �1 F� � ' ,�2� CONTRACTOR P R Q. Plumbing { �S�Dafe A liconf �". C�OTHES WASHER �„� � ��'� r� PP ��= r �" ADDRE55 4418 E. Chapman � :�i NnTICE TO APPLICANT: if, after making this Cert f wte of i!'��.'' : �y�"�y� �ption, you should�6ecome su6jecf lo the Workers W��. SWIMMINGPOOL RF.CF.PTOR CITV TEL.NO. h�` $'± �.� � ..npensation provisions of the�obor Code;yov musf fo 1h ��+ �AWN SPRINKLER SVSTEM Oran e 630-8441 � ',�Y� with comply with such provisions or this perm�� shall be�-.�� 57nTE uC. ,, .Xy�" �deemed revoked. � WATER HEATER � uceNse No. 443774 CLA55 C-36 + ?-",'�� LICENSED CONTRACTORS DECLARATION � `�y DISTRICT NO. PROCESSED BV "' "`� I hereby�affirm thaf I am licensed under provisions of Chapfer 9'�� GAS SYSTEM �OU7LEf5 {yy � �(} � �" ��� (commencing with$eciion 7000)of�ivision 3 of ihe Busmessf�.kp� OU1lET5 OVER . { �-�-� '`"�'„':.y and Professions Code,and my license is in fuil force and effed yi; 5 PER SYSTFM F�NA� { �:y.�. t� . //a/��r VALIDATION DAiE 0�� �" �s." b1�',�.,��License Number ��.1E��.Z/� Lic.Class �' "�ti -:i�� C�+ �ti; m�,F. �"�` FINAL / � � . /���,��� � , �'��` ConiractorP•R.O. Blllmhinff Date 7�2�85 t ' BY /°ra""`— i � su:t�. *�"-Y'�� I om exempt under Sec. 5��� �gy^:� ��� o � ��;� � ���.� �. ��;�� B.BP.C.tor Ihis reason �'•-�. � Plan check fee � ; �e"��i� Date: � "� ` � PLUMBING PERMIT ISSUING FEE$ S v `t��a� � Signature � } . � r.' I �r �� TOTAL FEE �/j � ,�j 7�'(�I� � ,,'. � a . P l a n c h e c k a l i c a n t " �'� � PP $�o a o e� o `J 1 �y�*,;� �� SIh�L:°AM':Y �' . �`�'� HOME OWNER-BUILDER DECLARATION � '� Name I.e n C -� r " `e6y affirm thot I am exempt trom ihe Conlracror s Licensei�'r�' u• « ,' � �-a s, . ��� Address �� ror me foiiowing reason(Sernon 703iS, ousi ese a a�:v?� �„y�µ^3M professions Code): ;� City Tel.No. � � � �, (' `''^� �+� ��`.r� ❑ X'�� I,as owner of the properly,will do the work and ihe t�7 S r � ��- �'s}`� �struct�re is not ntended or offered for sale (Sechon�� . #�.f. 7044,Business and Professions Code). � $, , � i ;, `�{-� CONSTRUCTION LENDING AGENCY � �t ! �` r I hereby affirm thaf there is a construt�ion lendiny agenry for��� - � ��' the performanca of the work for which this permit is issoed�� 1 }+`� (5ec 3097,Civ.C.). �,���. � ' �;� � �.'Lender's Name — �g� �j �'' �`�§" § '+'�Lender's Address h c '�",C� ► � I certify Ihat I have read ihis application ond state thol the� �. "�above informotion is correU.I qgree Po comply wiih all Counryav.`� � `q j r ���.`�ordinances and State laws reguloting Plumbing,ond hereby�.�, � � . >��a .,�, authanze represeMatives of this County to eNer �pon the�'� i'a6ove-mentioned prope�y for inspection purposes �^^ SEE REVERSE FOR EXPLANATORY LANGUAGE �., � 1 �a � i;^. ` � � � 5 gnqiVre o e�millee aie f ��,;. ... :.�'`�� ' , . . .. i „ . . . .: : .... _ � _ U ; _ . . _ ,. . .. . . z - - - . .z � �� �, ��_ �, �,��i� , , . � � `D�� DZ J O D N O�Z I � � � � I � �i-' � � �' . , , , . , .. , , ., • • v� t n ��Z�D Z Z � N D� , ; .�D O Gi mA � � D v O � � �X = a�o �!C . � I . - � D � A,D Z.�O�D Q� � � �'�I N - � � ! . ., , , � � =� ' �� 2 0 y(�, � � 7E�i� T W 1_ P �� � . � � Q � ' A� ..� I' � � I _' m � 0�1 Vrv 0 , I � �� , � � � ! � �-a `”' z. I � �! � m � � � �_. C � -' A � ' � � ' ^ � " � �y� 1 � f , � f i i ' � f � m <,: .. .. .. .>.._ , • :.. ,.. .. ,..;r _ , ' .;4'2,:>.�� � . � . „�s1.`;. 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