HomeMy WebLinkAboutNo Permit Number (1298)TIONIWfirm APPLICATION FOR PLUMBING PERMIT
that I havNSAiroNcate
of
c*nseIherebyaffirmThorIhaveacertificateofconsent ro self 76A667A
insure, a o certificate of Workers' Compensation Insurance, GE $171111EV. 10/811
or a certified copy thpof (Sec. 3800. Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 8-1030QZ ComtaonyO^aut Tract 32576 Lot 41
Certified copy is hereby furnished. BUILDINGFOR
Certified copy is filed with the county building inspec-
APPLICANT TO Fit L IN (PRINT OR TYPE)
ADDREM
tion deportment. NUMBER FIXTURE OR ITEM a FEE
WATER CtOBFr Diamond Bar. DotelG:.L L..'d..LAppfirpnt RPIVPTIPTP Plmho•
CERTTFICATE OF EXEMPTION IFROM WORKERS' G RATH TUB Pathfinder
COMPENSATION INSURANCE
srIOWER Er M. J. Brock RSonsRaeMleneeednotbecompletednthe -work involved bypermltisteroneMrttdnddollars (SItlO) er fess.) 4 LAVATORY
I vandy Hrot in the performance of the work fo which this 1 SMKpermhisissued, I shall net atnploy any person In any manner TEL. 81Breasoas19becomesubjecttotheWorkers' Compensation Lows. 1 DISHWASHER CONTRACTOR00 Belvedere Plumbing
Dare Applicant— _ CIOFHFS WASHER 00 ADa45 13350 Ector St. NOTICE To APPLICANT: If, after making this Cemficate of
pplion, you should become subject to rhe Workers' SWIMMING POOL RECEPTOR
CiFY 'Ef' Ivo. hlpenscition provisions of the Labor Cade, ya,v mull forth. I AMM SPRIMLER SYSTEM 62. 4401
with comply with such pninbia s or this permit shall be STATE LIC.
deemed r3rvoked. WATER HEATER L43NSE NO. 17 168 CLASS C 36
UCENS'fp CONTRACTORS DECLARATION DISTRtCTffO. P7,11D By
1 heraWaffirm Stas I am licensed under pravitiion9 of Chapter 9 1 OAS SYSTEM OUTLETS 6 O0 d/ commencing with Section 7W of Division 3 of the Business OUTLETS OVER dandProfession; Cade, and my license is in full face and effect. S PER SYSTEM FINALOVALIDATION
DAA /-t,.iacv
License Number 179168 tic. class C 36
Plumbing
FINAL `, y -G•' v O
VBrContractor
I am exempt under Sec. d
S&P. C. far This reason Plan check fee
Dote:
PLUMBING PERMIT ISSUING FEE S 1Q.50Signature
l0 5TOTALFEE •
Pwn check appl,coni
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION Name
yefsy affirm than I am exempt from the Contractor's license Address
s e r
1 for the following reason (Section 7031.5. Business and
Professions Code): City Tel. No.
1, as owner of The property, will do the work and the s77
structure is not intended or offered fa sole (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the aof the wok far which this permit is issuedperformnce
Sec. 3097. Cir. C.).
Lenders Name
Lender's 60dress
I certify that I hove read this application and stale shot the
above information is Coned. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize representatives his County to enter upan the
above -menti ed pr r f Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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