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HomeMy WebLinkAbout1727 SILVER RAIN DR (2)WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81 ) or a certified copy thereof (Sec. 3800, lab. C. ) Policy Na. Company Certified copy is hereby furnished. APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑FOR Certified copy is filed with the county building inspec- tion department. of APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM WATER CLOSET Dote Appli4ant BATHTUB CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER (This secfion need not be aomplefed if the work involved by LAVATORY thv permit is for one hondrod dollgrs ($100) or Igss.) I certify that in the performance of the work for which this permit is issued, I shot[ not employ any person in any manner SINK so as to become subject to the Workers Compensation Laws. DISHWASHER Dat6l�ppliccmkg 5-0W1cl4k_6 CLOTHES WASHER NOTICE TO APP (CANT- If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be WATER HEATER deemed revoked. LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS I herb ffirm that 1 m Licensed rider r Cho t 9 e y e a u p osrons vper (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in fu It force and effect. 5 PER SYSTEM License Number Lie. Class Contractor Date I am exempt under Sec. B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE f Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER -BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. aDG 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 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws r arin mbmg, and hereby out orize representatives t un to enter on the a vee men tinned pro f i n purpos Signature of Permittee Dote BUILDING 72 n,4 (.`e& ADDRESS f / R �rC FEE LOCALITY �>m 0Rae NEAREST *� l / / � • , G CROSS S fs' L OWNERMAIL ADDRESS l ! 2- �J CITY 1--06I3 TEL. NO. CONTRACTOR ADDRESS CITY TEL. NO. STATE LIC, SEE REVERSE FOR EXPLANATORY LANGUAGE 100,49 1 4.Ci FINAN. VALIDATION DATE L L j FINAL BY M Vf\,, �_0_09-1_ �t • s s s • S • e . _2 2 v C ,� U622-83 ( \ \ \ j z I36&±f§]k$% 7 -`i�55�$ ° \�§: ƒ}\\/2I)a|} / \e®&�v� a ,§»�-_f �°.2 0r, rt- r ` � ° ! 2 � a -o —D ee,o;.er)t �.. «� E.©§©« ƒ)�4)zEs§£� f\�()�/t§kt/» 9}'13 o {\ tE`f\%ƒ0,-"D .}$j|�{k§}� \\\ƒ\}®!I::c -Mo- $/«[ En.o-m!»Zt«a� 2iCL c§& , +��;=,|.�2 »022.•2�.0 ox \/\ta�«l".$$%ƒE � .2x fr 'a�!%(7\& 'a- «ƒ©e %ƒ§;e«�� . )ƒ&«kr"IQ76 k§ `-4��S.2�f� --\�|�§%m�E±;3:.;b $ �� E=0— �.=�!(�;�0§0tt%2�I 2�t30Z�B�_§�§§!�■•50 o�E���ozz2■k\\2t\» ±SEEk� )`JI�a/O{�=�22«&] �\�i�fl2\���-° /�ƒ§a»;t \:nM 0trE3 [§k ƒ�2»�.—.- \ ƒ • \ K z � \ � m � o � � w a§ w( \ § p s o■ \ § / / §J \ g 2 / / k E k E f § ! 0 �/