HomeMy WebLinkAbout1064A (5) ��.
� WORKERS'COMPENSATIONDECLARATION �swivw �
I hereby af£rm that 1 have g certifcate of consent to seit �e.,��2.0, APPLIC�ATION FOR PLUMBING PERMIT
� insurc,or a certificate of Workers'Compensatlon fnsurance,or . . . . � . -
-a certifi d coOY thcreof 5ec.7800,Lab.C.) � "
�Zcf.p:3�j-�� � COUNTY OF LOS ANGELES BUILD7NG AND SAFETY
Policy No. Company " � �� - � ������u4
/
� Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILDING / '
�r/� � � - ADORESS �7_ L/-�,�Q�
�Cntifled cnpy is filed with the cnunty building inspection NUMBER FIXTURE OR ITEM • FEE
Aepartmertt. LOCALITY
ate Applicant WATER CLOSET NEAREST
eArH Tue caoss sT. Di amond Bar & Grand
� CERTIFICATE OF EXEMP7fON FROM WORKERS' �
. . COMPENSATIONINSURANCE � SHOWER � OWNER presle of So. Calif. � �
(This section need not be com leted if the work 111YOIvCd L.4VATONY MAIL
AODRESS 4
by the pe:mit is tor one eun�red douus(s�oo) or�ess.) SINK aTv Newport.Beach � Te�.r,o. 540-050 0
� 1 certity that in the pedormante of the work for which this DISHWASHER � V �
'permit is issued,I shatl not employ eny person in any manner CONTRACTOR R70 Hondo COIISt. � ,
so as to become subjeet to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS � �
�Date Applicant SWIMMING POOL RECEPTOR - U
NOTICE TO APPLICANT:It,atter making thls�Certiflcate of CITV Ful l erton Te�.No.529-7391 W
'Exemption, you should become subject to the Wnrkers' LAWNSVRINKLER5YSTEM STATE I/ LIC. y .
Compensation pmvislone of the Labor Code,you must forth• LICENSE N ,S� 7y pZ CLASS �� z �
with compty with such D�ovisions or this permit shall be W�+TER HEATER
deemed revoked. � � GAS SVSTEM OUTLETS DISTRICT NO. PqOC SE�BY
� � L]CENSED CONTRACTORS DECLARATION DUTLETS OVER /�O -�
I hereby afGrm that 1 am lioensed under provisions of Chapter 5 PEA SVSTEM .
9(commencing wilh Section 7000)o[Division 3 of the Busi- FINAL VALIDATION
ness and Profeasions Code,and my license is in full force and 27 bld .tx7 DATE ��� �a ,
•ettect. � � � .
FINAL
License Number Lic.Class - gv ;iGr.�, �
Contractor R10 Hondo COtlpate � � �
� I am ezempt from the licensin¢requirements as I am a Plan check fee �30.D t�.�0 !d�E'L 82. ��
licensed architect or a reeisteted professlonal engineer pLUMBING PERMIT ISSUI E$ � �
� acfing in my professianal capscity (Section 7051, Bus-
iness and Professlons Code). � TOTAL FEE �98 50
Lic.or Reg.No. Date Plan ehxk app�icant - � . .
HOMEOWNER-BUILDERDECLARATION Nams Madole Ft ASSOC.
I hereby afflrm that I am exempt from the Contnctor's Addren 1820 E. 16th�St. _ �
License Lew for Ihe following reason(Section 703L5,Husi- Clcy Santa Ana, �{� Ta�.No.835-2548 - �
nas and Professions Code): . � ' I
� I,as owner of the property,am exclusively contncttng �
with licensed controctors to construct the project - � .�$'� Q��Q"a .
, (Sectbn 7044,Business and Professans Code). - ' . . . � .
#'• • •�• ••5
CONSTRllCTION LENDING AGENCY ' � ' �.
1 hereby affvm tAet there is a construction tending agency I'•�1 9&�5 0 �
for Ihe performance of the work for which this permit is '
issued(Sec.3097,c��.c.�. Securi ty Paci fi c�Bank - � •'•1-9 8.5 0�� � �
Lender's Name �
Lender'sAddress 4000 MacArthur, Newport Beach, CA � � . ►�2�18.-81 � .
I certity that t have read this apPlicetion and state that the �
ahove intormetion is correct.I agree to comply with ati County SEE REVERSE FOR EXPLANATORY LANGUAGE � -
ordinances and State iaws regulating Plumbing, and hereby - �
authorize repreuntativex of thie County to enter upon the � - � �
above-mention roperty ecttop purposes. � � �
����i � �a�f�� . . . .
�-9Tgna�ure of Perm�tee Date �- i � � �
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