HomeMy WebLinkAbout02_12_1987 - 21015 PATHFINDER RD (3) ,�
WORKERS'COMVENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �
I here6y,affirm Ihot I�have a certi4icate of mnsent fo self ]gq867A
� insore,or a cerlifico�e of Workers'Compenwtion Insurante, CE B77(REV.8/86) . . � � � . � •- ��
or a certified copy therco}(Set.3800,lab.C� - � - � � - , .
aty No�L Zll.(,b�a'ompnny ,C.d�.p�a'y?! COUNTY OF LOS ANGELES OEPT. OF PU9L�C WORKS
Certiiied copy is hereby iumished.
O � FOR AGPLICANf TO FILL IN(PitINT OR TYPE) BUp�� �J d�S ./A✓ . .
Certified copy is filed with fhe co�nty uildi in c-
. fiondepuriment NUMBER FIMUREORITFM Q FEF ��un, �
� Dote L�IZ��?. .AppliSoM � VJATERCIOSET . . . . �AR�T ' ' ,
CERTIFICATE OF EXEMPTI F ORKERS' � BATH NB . CROSS ST. `'A:R,��� ��'��S'�": � -
COMPENSATION INSUR E , S��Q � ,/ . CLGl d � '
{This s�efton n�ed�ro1 b�wmpl�Nd t!th�work imrotwd by
th�permif la for om hu�r�d dollen(�100)or In�.) tavATORY q�ppRE55 Z /�i; L d� b .
I ceHify ihot in ihe pCr{ormanca of ihe work for which lhis � . �
_ perm{I ia iuued,I�holl not employ any penon in any manner �� � - ��TY � � � ���•� . _ '_
so as to become subjeci io the Wakea'Compenwtion Laws. Di5HwA5HER - - � �
- CONTRACTOR �� — .
Date � �rplicuol CIO�HES WASHER � � � . �
NOTICE TO APPLICANF: IS, after mckirg rhis Certifica�e of ���� • ��' �� i
ERemplio�, you should betome subj,eci �o Ihe Workera' SwIMMfNGPDOIRECFMpR �
�CompBosation provisioos of Ihe 1pFrx Code,you most forth- � ��tt .f ��'�'��/" l
LAWN SPRINI(IER SYSTEN -
winc �omply wirh sucb povisions o� this parmit shall be . STA -
deemed.evok�ed � - � - WATER HEATER ������ � l
� � LICENSED CONTRAC70RS DECLARATION��� rnstaiCr no. ar
�- 1 hxebY�irm thor I am licensed under provisipns of Chopfer C � GAS SYSTEM OUTIFiS '�_ . .
�(mmmericirp wi+h Section 700p)of Divlaion 3 of�Ae Busineat , . puryt7spyEp . '�'
ond Rafessions Code,ard my licame is in fuH fpce ond effxt. 5 vER SYSTFM FINAI
oA� �_�..- vau�arioN o
License Number b Lic.Closs f�/ V
,jI/GJCt,'f.id+f pj�'1 _p' FINAL �
Controclor Date 2��' s/ BV � -
�. I am esempt under Sec. �3 5�.9 A W�,
8.&P.C.ior ibis reason � . �. . • • •5 . � �
Plan check fee =
Date: p�UMBING PERMIT ISSUING FEE S . I • + 1 6 5 0 � .
Signaturo � '
TOTAL FEE �� . • • • � G�J O c=i
� Plon check applicant �2� 3—a 7
SINGLE FAMiLV �
'� HOME OWNER-BUILQER DKLARATION Name � � � � - - - �
I hereby affirm that I am exsmpt bom the CoMrattor'i Ucsme Addreaa. . . - . . . . . .-. .
Low for the following reason(Sec�ton 7031.5,Butinese ond
Profeuions Code): City � Tel.No. �
❑ I,cs owner of the properry,will do the work ond�he �
strudwe is�nol Intended or offerod for sa�e(Secfion -� - - �- � , � � - - . . . ..
70M,Busi�ess ond Crofessioro Code). - , '
� CQNSTRUCTION LENOING AGENCY - � - -� - � - - � - - �- -
I hereby affirm thot thxe is o comvuctlon lending a9ency for
the performonce of the work fw which thh permit is iuued -- � - ��-- - � -��� - �- � � � � � -�� � � - � � �-
(5ec.3Q97.Civ.C.).
_
Lsnder's Nome � � -
lender's Address �
I cerlify that I iwve reod this applicalion and a�ate�hat rhe . . .. . . _ . _ . . _ , . . -
obove iof«matioo is corrxt:i ayree�o comply with oN Cwmy .
ordinences end Sta1e s r uloting Plumbiny,end hereby ,. , . _ . . , _ , . _ .
ou+haize represen es o �his Coomy to en�x upon�he � �
above-meM' n open or inspec+ion purprnes. . � . .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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