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HomeMy WebLinkAbout1171A ._ _ _ __ _ __ _ _ _ _ __ _ _ _ _ _ _ _ WORKERS'COMPliNSATION DECLARATION � �eaea�w � � � ' � � . � h�«nY .,ff;�»� tha� 1 have a certificate ��f���„sent t�5��e �Ea,>,x�a; APPLJCATfO(y FOR PLUMB;ING;.PER;MIT. insure,or a certificatn nf Workers'Compensation tnsurance,or�" ., , ' � , , . •� �� � � �.. �,.. u certified copy thereof(Sec.1800,Lub.C.) � � � �' � ��� � JC I�','�'�i� / COUNTY OF LOS ANGE LES BUI LDiNG.AND SAFETY Poricy No. ComPxnY (���CY'C:,a"� �. . � . , .. C ❑ Ce[tified copy is hereby furnisheel. ' FOR APPLICANTTO FILL IN(PRINT OFS TYPE) 9UILDING C� J� ' � � ADDRESS „� S�/ � "3�'GL'"l��F^', Ci3F�i1" Certified copy is filed with the county building inspec[ion - NUMBER FIXTURE OR I7EM • FEE �. �epa tme // ' IOCALITV (� � r'^ ,�r^' - �' ]-�. WATER CLOSET ,�,e F_'.{�✓l('b�.� C�.,t` � yr.�.' ^ Date • � AppliCant H��'�.'P�L_ ���� NEriREST / BATH TUB CROSS ST_�iy.r.-,,.i'�,�...¢'.i.q� Ift.-���t„.. �...� � CliIiTIPICATG OF EXEMPT[ON PROM WOKKERS' . — " � - COMYt.NSATION INSURANCN: -, SHOWER OWNER �'ri� ".r Z � .}P N��- - � ' _— r�l� ':. � LAVATORY MAIL .(This section rteed not be completed if the work involved � a�oResS �Ci,bv� �by the permit is for o,�e hundrecl Jollars ($100) or tessJ� SiNK �y�7q >- : CITY TEL.NO.' - �-� � I cerlify thut in the performance of the work For which this� ���z� p OISHWASHER U ��permi[ix issued,1 shall not Cmploy any perann in arty maimer . CONTRACTOR ���,i�,.�„y�� .so as to Aemme subject[o the Workers'Compensation Larvs. � CLOTHES WASHER - �ry r� �� � . Date Applicant__ ADDRESSI���� ���w �f.C:G%� y,� �� � SWIMMING POOL RECEPTOR ,� � NOTICN'TO APPLICANT:If,after making this CertiCicate of., CITY � � , TEL. �'�_�y�� L1A t'.xemption, you should becnme subjec[ in the Workers'� LAWNSPRINKLER5YSTEM � STATE LIC. ?!1 � ComPensuiion p¢ovisions of the i.ahor Code,you must forth- � ��"��^� (" �, with coinply with such provisions or this permit shall be WATER HEATER LICENSE NO. ,j! CLASS �� �' �deemed revoked. � DISTRICT NO. PROC SSED BY � � GAS SYSTEM OUTLETS I - L[CHNSlillCONTRACTORSDBC1,A1tATION OUTLETSOVER / /i �I hereby affirm that I am licensed under provisiony of Chapter 5 PER SVSTEM � �� �K"" �'��'^"��'K-"�� , �9 (commencing with Sectiun 7000)of Division 3 of the Husi- p FINAL � `' nusc�and!'rofessiuns Code,and my license is in full force and ,G��:.'r' 3�'> Y" �r.y OATE �.�,�(3,.�... VALIDATION � 'effec4.� i3' l,�1�1C'�Ci�.�'l.. � ' Lice�>e�Number����7 Lic.Class (+�E' SC•y� FINAI . BY l���i'_i . Contructor�en'tK t';:tJ��•,x�S pate /x,r l7��bwl . . � I am ezempt from the licensing reyuiremente as I am a � Plan check tee ' licensed architec[ or a registered professional enginucr pWM81NG PERMIT ISSUfNG FEE$ acting iit my professional capacity (Section�7051, L3us� t����" � iness and Professions Code). —TOTAL FEE s, � . . � �V r Lic.or Iteg.Nu. Date � Plan check apPlicant q!r HObiF OWNi:R-AUiLi)Ek llEC1.ARATION Name �1�1 7.1 A ' 6 1 herehy xCtirm fhat L um exempt from the Contructor's Address +f. ..C � '` - •. " .•e ioiiuwing rcuson (�eciion 7u3i.s,8usi- . �CitY � Tel.No. � 'r- - ` ' -" ness and Professiona Code): . + � �� 2�O � I,as owner of the property,am exclusively contracting . ; � with licensed contractors to eonstruc[ the project a �'1��n J�� (Section 7044,Business and Professions Code). � i230�81 CONSTRUCTION LENDING AGBNCY �� . I hereby aTlirm that there is a cortstruction tending agency . � for the perfonnance of the work for which ihis permi[ is � � issued(Sec.J097,Civ.C.). ' -Lender's Name Lender's Address � I certify that I Itave reud Ihis uUV��cution and state that the . 'nbove inPormation is correct.I agree tu cumply with utl County 5F.F.Ri:V13R5E I�OR EXPLANATORY LANGUAGL urdinances and Stute laws regulating Plumbing, xnd hereby � authorizc representatives uf this County to enter upon the above-men[ioned proper[y fur inspection purpuses. � � ��... �'r�.;.{� 1 z,/��'��i Siy��a[urc of Ycrmittee � � � c yG n f Iply N,�l�i . "n :� ➢ C -1 N ��m,� �� `� ;`�I-� � ��'m � �j7�;v .. t�ty� I �.- . �i� Z �1`,Z � r- f�' o ' �,� 'n,�'j � �'�J` G� C � D - Oi . • ; �� 1 z x;T' � � g � � -+, o �• �oD I I O g G ��I �r ' �� Z �s� ' p �.. 'n � ��;� . � ��� Ri � m � � � � ��,1 '6 ' `� . �t �, , .. � o � =-� ��� " � 4 `1I � 1?I � �- .� � . ��; , m ;.' v; � _ .1' i � �' � 1 . 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