HomeMy WebLinkAbout1295A ��'; > -.�:€; „ +�.:"�� �^3:,�v<' a.'.�.;�<y t �{'ns� .� ::: r ,Y^ 'rr� n��q�.'s4� `�£�';.:.ti.�.#s �, t�.� �Ati FkS a2',..5.:;t§ c."�i"s&.�':. ; ,��;; � ' ¢ ��.-.
� ' . ; ;� : � ��a„i ic'�.��¢r'A A'�p'V�,j �� R x t �r ' r �' 3 �.,�{'^.,5 h Y�t�S'�' r'�
� ���� •WORKERS"COMPENSATION`9ECLARATION� ��� �'�,h f��d s`'� K �' r
d�� �3� �s a ;APP�r+C�AT`�� FOR�PCiJ1V��B�NG"�P.ERMIT ' f $ ��� ��;�
�,` R. 1V
t �(��'hereby�'affirm ihao I have a ceriifimte of consenPto self ^rj76A6G7A�'��'y�` `�p�x"V.',� � , ' � � ' . � �"� � , ' F� ��,,,, �'� y '�3 '.,��'� 7��':
� ,nsure� or a certificate of Workers'Compensation Inwrance� dCE SV(REV to''!sl).�';'y� ; : � � � , �'�. � � � ' ��,��3e; ;y�x¢'w.��� ��,'{
.or a certified copy ihere5o�f�(Sec.3800,Lab.C.) aT �: - w "`"'��: COUNTY�OF LOS�tANGELES � BUILDING�AND SAfE7Y �'�"' �� � n�n"� �'� � "b�
'`..�'Policy'No.�T�rJ��.s28`Cort,Pa�y Farmers � ���I,,�� r r�s",�; . . � . . +,+� 'r�iv�yAa��tA,,��S'��'t. - 5;;.
.,� Cerhfied mpy is hereby furnished. �3'�'ff`� � � �
g�5�' FORAPPLiCANTTOFILLM(PRINTORiYPEj BUILDING 1435 St Stonecrest P1ace E�
yy Certified copy.is filed with the county building mspec $�a� ADDRE55 ��:
�''� 4�on department . 9+ NUMBER Fl7(TURE OR ITEM (�il FEE �e .
LOGA�ITY Diamoad Bar .;
.::Date ��2�85 ApPl�cant p R.O P1U1riI�in� ��� WATERCLOSET � � -�---� . '��.�,
NEARES7 't}4,
i � �'v'�. � CROSS ST. . �;;
;� C E R T I F I C A T E O P E X E M P T I O N F R O M W O R K E R S `� BATH T�B L � �.�a � ..
` � COMPENSATION INSURANCE � �� OwNER � ' ��i
z�?x �;,�;, sHoweR Bramalea Limited �� �,
-,(This section naed not be complefed if the work involved by y MAIt '"� 3 j
i,'��the permit is for one handred dollars(SI00)or less) � LAVATORY � {✓7� ADDRE55 3151 Airwa A e. E �fi� ±�,��
a y.,'�`I�erirfy that-in the performance of Ihe work Sor wh�ch this� � � �_p
p x�:permifisissued,IshollnoYempioyonypersoninanymanne ;� SINK � CI7Y Costa Mesa TELNO$SO-ZOOZ � -
dF��so as to bemme subject to ihe Workers'Compensat on La s � �' ��
� t . � OISHWASHER '� CONTRACTOR P�R�Q. Plumbin i# ��`i
�'��'�`ytiDate Applicanl CLOTHES WASHER (J ADDRESS � �'x� -ti'�
'� 4418 E. Chapman .,, _ :r
��' ��""',�ICE TO APPLICANT: If, after making ihis Certifimte of ��`
k�`�?#'. �rlption, you should become s�bjeci to the Workers' ��` SWiMMINGPOOLRECFPTOR ��"��
CITY TEI.NO. `'�
w �..mpensafion provisions of the labor Code,you must forth-`r� LAWN SPRINKLER SVSTEM ra 2 - , "�'�
��" with comply �Ih su<h,provisions or Ihis permit shall be;i�'�- S7ATE 443774 ���� Ci-36 #
�-�'" deemed revoked.. ' � � ky� / WATER HEATER � uCENSE NO. CLASS ��
LICENSED CONTRACTORS DECLARAT�ON '� --- DIS?RICT NO. PROCE55ED BY � - '
� � � � � -� GASSYS7EM OUTI.ETS �
�,�. I hereby affirm Ihat I am li<ensed under provisions of Chopter 9 � ��{ e _�,�
�� (commencing with Setrion 7000)of Division 3 of the B�siness- puiLEi50vER
Mr�pnd Professions Code,and my license is in ful)force and effecl �, 5 PER SYSTEM fINAI �`"�
£,,; ,��h� DATE P�i//� �,S- VAL ATION 1 � i
y, licenseNumber 443774 LicClass C �h .
�� FlNAL ��' �
F :Contractor P•R.O. Plumbin�a�e 7,(�SS �a°' BY ��`P''� "`� �� -
� +q`❑ I am exempt under Sec � ���Ty� ����.���
� t �4�' B.&P.C.for�his reason ��� — � ��
�, . Plan check fee
I� � Dote: ` .
z'�_; ��f;'.; PLUM8ING PERMIT ISSUING FEE$ CS �� =+, 'j �ti'�� �
f �,� Signature — �y, '_, . � n
; n'r, �ti�,��, TOTAL FEE �i� �� �.,� e n�
� �`� - 3�: �'Plan check applicant �r �,��J' �,r
x�,, SINGLE FAMILY �`�:t ' ;""
yst�= - HOME OWNER-BUILDER DECLARATION �y � Name .. . s � .�,� `� �
� ieby aHirm that 1 um ezemot from the Controctor s License., �
-��� .'�for ihe following reason(Sedion 7037.5, 8us ess and''`�}tn "
"',�Professians Code: ' �'�� [�(.1 ���'`5 ; ..��
) r,�.-:# C ty Tel.No. ,
£i ❑ I,as owner of�he o ert will do ihe work and the �+ ;� t
Pr P Y. �v � t V",
siructure�is not intended or offered for sale (Sectron,�, � , � s �
��f� 7044,Business and Professions Code). ,d`r.�"u' � '
��;': ��: h.;
CONSTRUCTION LENDWG AGENCY � h•� � 5
�a�I hereby offirm Ihat Ihere is a construcrion lending agency fo d?,s�� {
� „�the performance of ihe work for which Ihis permit s ssued''�j; ' �:
'��(Sec 3097,Civ.C.}. � � ; �,;ti' , ,.�,j
4i`�s
"��Lender's Npme i'- �'
t4;�
r r'!�Lende_r's Address �".' � �a
a�y I certify that I have repd ihis appiimtion and sto�e Ihat�he�;s ;' . :
: above information is correct.I aqree to comply with all Coumy�;' : , y v :!
�,F, ordinonces and State laws reg�loting Pluinbing,and he eby�u;. ;^, ,� ��
- authorize representatives of ihis County lo enter pon the t '
? abov enfioned'proper�ty for inspection purpo es ��. `, � �.��x'�,�
�•; � SEE REVERSE FOR EXPLANATORY LANGUAGE
_ -y � ���;� .
ign�lure of Permit D te �'"=� �
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