HomeMy WebLinkAbout1288A �,;y�r, `� �;;�.,. .:���.. � ;'::z� '��.. ;.-..,�.� r:���+��t���� z�`x�<+��C'ia�����,.y,��y� �, ��;:.:�. 4 -��';:. 4 �.�vha a� : S,�-6.t a��.,�.. e �¢����`jrs� �
� �.��� �`�WORKERS"-COMPENSATION'DECLARATIO��'� '•` e�''`� <�` 5� '�� � � u,: � '�
�,�� � ��►RPLICATt�IV��OR�PEI�IVtBtN�P�RMIT'`a���s��;� ,
� ��f��hereb�'affvm Ihat I have a certiFicate of.consenNX.lo sel 3';�,;76A567A 4�e�y � �" � �"' ,�.n)I'"i '
- inwre,�or a certificate of Workers'Compensation Insurance�+n!�r^CE e17(REV 10/Bt1�'�,�� � �' � y �, � ��s� � �},�,�t�'� ���:�:
o�a certified copy thereof(Sec 3800,Lab.C) s�7yw r, ���"� COUNTY�OF LOS�ANGELES � BUILDING AND SAFETY $+°�'a�p �� ^"7 '�"'F° '+
pY. . �i.??` �#;' , )5S�'k�;'a�a�i' kYi�V. i '.'�:�
�cy No.NoS07528�ompany Farmers a�,�' r ,,���,�; � � ,' �µa��
�` � Certified copy is here6y fumished. �:`�� - � . ��� '�
y�� ,��.yh� FORAPPLI�ANTTOfILLW�PRINTORTVPE) qDDRE55 1419 S. Stonecrest Place s +
C.erpfied mpy is filed wdh the county buJding inspec s
sj;�, fiondepariment. - , �^' NUMBER fIXTUREORITEM rz FEE � �i'
,�;� � LOCAUTY Dj�amond Bar.
�" 7/2/85 e�. �5 wareaaoseT � �
irDare Applicant P.R.O. P12imh�ncu�;r,�' �/ NEAREST �- :"�.i
�f� CERTIFICATE OF EXEMPTION FROM WORKERS y�.�` U.p � CROSS ST.
sb� . �. BATHTUB �� .�t,
�'.; ' COMPENSATION�INSURANCE '��•y�>+� SHOWER / � �WNER Bramalea j,ltrilteCl','- ,�, '�'�,
�'�(Thfs cedion need not be complated it tho work involved by�,�";�. ,� MAIL = ��.`
xiry��fhe parmif h for one hundred dollars(5100)or less.) '�^):.�i�= IqVATORY � /j'� ADDRESS 3151 Ai a Ave. $'CE. � k�. '�,�
`�b�.l certify ihqt in ihe performanw of fhe work for wh ch ih s�.�� SINK CITY TEL NO. X�
M�;�perm�r is issued,I shail not employ ony person in any manne���,{., � Cos ta Mesa 850-1001 ' �at`�
so as�to become subjecf ro the Workers'Compensat�on Laws � DISHWA5HER
x�w N �� G� CONTRAQOR p,g,0. Plumbing
u�u�.
.�9�Do�e Applicanf ����? CLOTHES WASHER ADDRE55 �
a�r�,. 4418 E. Chapman �
�r ICE TO APPLICANT: If, after making Ihis Certificate of.,,�, ';
k�l" � �,¢d SWIMMING I'OOL RKEPTOR �
� 3r�ption, you should become su6ject ro rhe wo ke s,�.,..,„� ��TY Orange TE`."o.630-8441 �
2 . �wil'Ipensation provisions of Ihe Labor Code,you must forih`� ?� LAWN SPRINKLER SYSTEM ,��r S
� �. '��with comply with such.provisions or this permit shall 6e.�i.x STATE LIC.
deemed revoked. GM,�: / WATER HEATER /' (�� uceNse n,o. 443774 CLA55 C-36
�4!���'� LICENSE�CONTRACTORS DECLARAiION -;���, --l-�— r' DISTRICT NO. PROCESSED BY � �;
�'��� i hereby�affirm thai I pm licensed under provisions of Chapfer 9 ��� GAS SYSTEM „� OUTLETS (,r� �' '�.
�� (commencing with Section 70D0)of Division 3 of.ihe Business��, OUTLETSOVER � U �^y
'..:. .
� r ��and Professions Code,and m license is in full for<e and effect '�` 5 PER SYSTEM � �..
�� v ,� FiNa� VALI ATION �n;
� ��• 443774 �; DATE /�'�o��f �..:
R�,License Num6er Lic.Class C 36 ""�F� r
�A � FINAL J �':
+s°�' Comractor P•R.O. Plumbiri�ate 7/ZJRS ��: BY /�-d�8'�"� �£!
�a ❑ �i"
�� I am exempt under Sec. ��,�' ����,
:� ��
�f� e.sP.c.for rhts reason is'mr plan check fee ' � �'`{
�; '�w� a
9 �, Date: �t��'�j` pLUMBING PERMIT ISSUING FEE$ �U �R7 a "'?;
3 �
� p '� , Signature '��4,
�., �'! TOTAL FEE �UU S�
�kr� _
� ' �, ,�� Plan check appl�cant . , '��R i�
! M SINGLE FAMILY �a'p f.� �
HOME OWNER-BUILDER DECLARATION x:�. Name �`m ° � m J
� . .�`,�� ',eby affirm thm I am exemu�from the ContraUor s License�tr;,. , .
� �fo�the following reason(Sedion 7031.5.Business andy'���s'_ I '�° 1 l;U.�lr -
� �;��Professions Code): �?r�. Ciry" Tel.No. a , r. ` 'i
�3�:❑ I,as owner of ihe property,wili do the work and Ihe�j � � l�Q„L c
y,.�, structure is not in�ended or offered for sale (Sechon,,��',��g� ► j�� � ?-��tJ �:.
� .,�" 7044,Business and Professions Code). ,
ty
N �:� , f ;�>
� .���� CONSTRUCT70N LE DING AGENCY
�' I hereby affirm that ihere is a consirutlion�lending agency for�,k{w;; ���
"Ihe performance of the work for which-this permit is issued+c y
{ ��(Sec 3097,Cb.C.). X�; �''
.,��*�. , �� , i
� �;,.: �'..�.
�h Lender s Name �"���' �
i � r'
��,
�; Lender s Address u:�ai"; 'rl
s�� I certify fhat I have read ihis application and stale that Ihe�44�, , V$
� above information is correcr.I agree to comply with all Countyr� ;
?^.ordinances and State lows regulating Plumbing,and herebyY� V`
.puthonze represenlatives of this County lo enter upon ihe� h
`''�. abov entioned properf�for inspeUion purposes. �- �
�'�� r �� SEE REVERSE FOR EXPLANATORY LANGUAGE
�,<f`
i � ��= �•s�` .
I �igna�ure of Permittee D e ��' �
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