HomeMy WebLinkAbout1285A A:a, .�„ ..:;d 2��.v2:,.��:.F`'F'ila.9�...��`�`+'�.� c�';u>�.�,, y:,� �N 3 -�.vx ����� 4 e?ta�.,„^� �. x�i:a.�awt s�r,;::,>4� ' 4 h:$,1�a.� �2 E�G�r.n+f,�Far�.,.i�s w�rs � 's�£� y�� �� ,�
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2;y,�""`�'�;,WORKERS'>COMPENSATION;"DECLAR'ATION � z?E�'s� �-;��q�+��a�� AP.1�'.`ICATIVI��PO ,:��:�UM;B;LN �`�P�ERMITx���"���F � at `� �,�
i � (bhere6�offirm that I have a certificafe of consen to self++�'� +� �w P� '- ' � �' i � ' G��;,
e v" F,�. �ea,an�a: + � �, � r�r�.. "��,:�d,�hr+`
�insure,or q certificate of Workers'Compensation Insurance p CE-817(REV t0 8l)�, � � � �. �. ", . �' . . ;4 . .�r. � � '� °`YM+"��yk�,�y,� �i�
��t �for p cerfified mpy ihereof(Sec 3800,Lab.G) `�' � ' CAUNTY'OF IOS;ANGELES �: � BUILDING AND�SAFETY ��i�'� .r`w.�,�� . �'
,e ��.� � t�� �. .�. a+ i�5?�,a;i # � a�
'Polic�No.NO7O�SZH�om a„ Farmers � +� � �^ �"��a�` . .. . �,��� �
� v a v �,-,t R , ��e > .�a�:n„�:.Lok'�3.� �'
`r� Cerfified copy is hereby fumished. °�� '� ,;'
H: � ''�� FOR APPLICAN7 TO FILL IN(PRINT OR TYPE) �BUIL�ING �, ,
� Lertified ropy is filed with ihe munty building mspec- *��� ADDRE55 1427 S. Stonecrest Place ='
�za �tion depariment. � .M,,�� NUMBER FIXTUREORITEM rQ FEE �OCALITY '� ���
��2�85 Diamond Bar u
rDate A licanr P R WATER CLOSE7 �� � x "��
NEARESi
r ' pP �'6�s � ,� � CROSSSi. �. .
CERTIFICATE OF EXEMPTION FROM WORKERS �� �-- 6ATH TUB
COMPENSATION MSURANCE SHOWER � �
� �„� - �';- � OWNER gramalea Limited �
�r.(This section need nof be completed if The ixork in olved 6y����R� �.�y �i '�
� �4he permit is for ona huedrad dollers(5100)or lass) �, e„3 LAVATORY VV ADDRESS 3151 Airwa Ave. Ste, N ��
��: �'I certify ihat in.ihe performance of tHe work for whch�hs"�g''� " '�'
� SINK � ��TY Costa Mesa TEI.NOraSO—�OOI � � 'f
,permif is issued,1 sho(I not empioy any person in any manner-; �
�' �-y�,sa as to betome�subjen to�the Workers'Compensmion Laws �` oi5tiwn5tiea /� Gl� s
� ,. � � t(J CONTRACTOR p,R.O. Plumbing t�
I ha��Dafe Applitonf - CLOTHES WASHER ',fi�;
�z,,.� �' 4418 E. Cha man y,.
,x�St°� �. ADDRESS
TICE TO APPLICANT, if, after moking ihis Cerhficate of�:�"' S.
�?� f'on, ou should become sub�ect to fhe Wokers SWIMMINGPOOLRECEPTOR
p p� Y I CITY Qran e tEi.No.630-8441 '.`'y
I �,�,� ..mper.sct:on pro,v:s�cns of ihe Labor Code,ycu m�sf for h,�� �AWNSVRINKLEI25YST[M g � i��
} � ilh tomply with such provisions or this permit sholl�be. STATE LIC. �� ��
�n''g deemed revoked.�� , ��,., WA7ER HEATER uc�Nse No. 443774 CLA55 Q-36 � ��.�
�± .LICENSCD CONTRACTORS DECLARATION . ��' —� — DISTRICT NO. PR ESSED eV
e��i �I hereby affirm that I am licensed under provisions of Chapter 9����� GAS SvSienn OUi�eis � j� -� ���.
�f� ,(commencing with Section 7000)of Division 3 of the Business.'�,���• ouiteisovee � . �3' ;
� and Professions Code,and my license is in fuil force and effect."'�� 5 Pee SvSienn FINAL �``
��;� �, VAL DATION � �
`��+ License Number 4'4'3774 ��Lic.Class — DATE � �6 �'� .�^%,,.!
FINAL� . ��t�.'+
,� . . 8Y (�� �'�.
�r Contracror P•R•0. P7.umhlri�Date 7�2�85 r ' '"'�'
„•,�,'�,',,' ��� .6A,i�'�.
��-`.��❑ I om exempt under Sec. �i �
'���� 8.&P.C.for this reasoo .� � �'. �
I.��"� = Plan check fee �
�:.� �� �s r k ,
I� Dcte: � p1,UM81NG PERMIT ISSUING FEE y" O � � �
f
I,+�o Si�nature � j;!r � a a c �+
r�'�'. � �tt-: 10TAL FEE �f`�a �S�
l �� � � `�'
� � �,z�0 �;
n'$r;. � S�.. Plan check applicnnt � � v„x �t
� SINGIE PAMILY z. : " `' -c �t -�
��� HOME OWNER-BU�LDER DECLARATiON � Name `��
r ��� �Eeby affirm that 1�m exempt from ihe Conlratlor's L censeg,,, , � � � � h� ���
�,��y��'. :for the following reason(Section 7031.5,Business and��� �""' � �,��,,
��g �Professions Code): . . , �� City c, Tel.No_.—� � X�•
� �❑ I,as owner of the property,will do the work and the��' .�
ali�i�
''- structure is not intended or offered for sale(Sec�wn i+'y� �
� 7044,Business ond Professions Code:). tpL��� � , �'4't
� �'�". �ii.� � �-:
w �. CONSTRUCTION LENDING AGENCY � ti.� �
�,p��I hereby affirm ihat ihere is a wnsrroction lend�ng age cy fort."� t } �'•
�;'the performance of ihe woik for which ihis permit s ssued?��;;.;;;'-," !
r ' (Sec 3097,Civ.C). ' � �:'
� ���
���;'�Lender's Name �: F Y��
� ,a �x�� �
�
�§ Lender's Address t �
fx�'I ceriify that I hove read this application and siate thot ihe�y � ,t� {
, t 5�,o6ove informn�ion is correct.I agree to comply w�th oll Co nt.��5
� �t.
��ordinances and State laws regoloting Plumb�ng,and"he e6yi p�
f ��authorize represental� es of ihis County to enfer upon the�':� �!' '
� i above menlioned prop rly for�nspec��on purposes �"f;� � � ��
s /�� ���- ���q�y SEE REVERSE FOR EXPLANATORY LANGUAGE
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