HomeMy WebLinkAbout6954ATIONWormthatIhaveSATIONcateofcorse 76A667A
APPLICATION.FOR PLUMBING PERMITwherebyof{;rm that I have a certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance, CE 817(REV.10/91 i
or a certified copy thereof(Sac.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 608d26fiCampany Great American
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 1016 SwnmitridCertifiedcopyisfiledwiththecountybuildingmspec- ADDRESS ge Drive
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY TR# 42571 Lot Diamond BarDate Tq _gppiicont Tva vPrtnn Rene WATER CIOSET
NEARESI
4
CERTIFICATE OF EXEMPTION FROM WORKERS' L BATH TUB CROSS ST.
COMPENSATION INSURANCE
SHOWER OWNER M.J. Brock & Sons, -Inc.This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or sees.) LAVATORY MAIL P.O. BOX 0c:ADDRESS 35IcertifyThatIntheperformanceoftheworkforwhichthis
permit is issued,1 shall not employ any person' any manner. SINK CITY Brea CA 92622 TEL NO52 170soastobecomesubjecttotheWorkers'Compensation Laws. /
DISHWASHER CONTRACTOR Leaverton Bros., IDateApplicantCLOTHESWASHERADDRESSP.O. BOX 17118NOTICETOAPPLICANT: If, after making this Certificate of
I.. •°jmption, you should become subject to the Workers', ' SWIMMING POOL RECEPTOR
Rnpensation provisions of the Labor Code,you must forth- CITY Trvine CA 92713TEL.NO. 863-1180
with comply with such LAWN SPRINKLER SYSTEMYpyprovisionsorthispermitshallbe STATE UC,deemed revoked. i WATER HEATER LICENSE NO. 191 6 CLASS C 6LICENSEDCONTRACTORSDECLARATIONfDISTRICTNpPROCESSEDBYI 'I hereby affirm that 1 am licensed under provisions of Chapter 9z GAS SYSTEM OUTLETS
G/ 4 .,'(commencing with Section 700D)of Division 3 of the Business y
OUTLETS OVER
P and Professions Code,and my license is in full force and effect. $ 5 PER SYSTEM FINAL
71
VL LIDATION
DATELicenseNumber191969Li[.Class C$6 ,, A'
3/19/87 ' FINAL UContractorLeavertonBI'OSDate BY
I am exempt under Sec.h
BAP.C.for this reason
Plan check fee
Date:
5 4 5 It FSignature_
r1
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE a• u 5
Plan check applicant
SINGLE FAMILY e ) `Za 0 W
HOME OWNER-BUILDER DECLARATION Name
hereby affirm that I am exempt from the Contractor's License f s ; ,'UriAddresswforthetollwingreason (Section/031.5,Business and
r'rofenions Code)- lJ.i.U"b!hr, a Y Tel.No.
ir I,as owner of the property,will do the work and the,
structure is not intended or offered for sale(Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY G
f{ LI hereby affirm that there is a construction lending agency for. Y
R he performance of the work for which this permit is issued
PSec.3097,Civ.C.),
777s
Lender's Name
Lender's Address
I certify that I have read this application and state that the.
I above information is correct.I agree to comply with all County,
ordinances and Stale laws regulating Plumbing,and hereby,
i authorize representotives of this County to enter upon the
above-menyoned proi forinspectionpurposes. '
17-V,/ 7 'F
SEE REVERSE FOR EXPLANATORY LANGUAGE
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