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
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