HomeMy WebLinkAbout10_20_1982 - 1817 PEACEFULL HILLS RD ,
WORKERS'COMPENSATIONDECLARATION oawssvw n � .
1 hereby atfirm that [ have a'certificate of consent to seff �fi.,,,=-.o, APPLICATION FOR PLUMBING PERMIT . . �� .
insure,or a certificate oi Workers'Compensation Insurance,or � � . � � � L� :
a cerliPied op thereof( c.3800,La6.C.) . - - � �
�p�_���—��p Y COUNTY OF LOS ANGELES BUI L�111jG AND SAFETY
icy Company ���— ����`�� �
� Cer[i copy is hereby tumish . . FOR APPLICANTTO FILL IN(PRINT OR TYPE) BUILDING I .'
Certi£ed copy it�led with the county building inspectio
NUMBER FIXTURE OR ITEM � FEE ADDRESS �
d peHme . � LOCALITY��,Y,�
�0���, WATERCLOSET Of� - �
Date Applicen � NEAREST ..
BATH TUB �) CROSS$T. �"Lr � '� �
CERTIFICATE OF EXEMPTION FROM WORKERS' � � �
- COMPENSATION(NSURANCE SHOWER � OWNER
LAVATORY MAIL y � ,
(This section nced not be compkted if the wo�k involved � ADDRESS � �p - �.✓ } ..
by the pe�mit is for one hundred dollus (St00)or less.) �
SINK � CITY i6'�� TEI.NO 1 �J� � - _
— 1 certify that tn the pedormance of fhe work for which this � OISHWASHER - V �
permit is issued,I shell not employ any person in any manne[ �/ ��� 1 CONTRACTOR
so as to become subject to the Workere'Compensadon Laws. � CLOTHES WASHER (O I"o ADDRE55 � �_ v1' : �� - , O
Date� � AppliCant � - SWiMMING POOL RECEPTOR `�J�/ U —
3 N�—�y'L TO APPLICANT:If,after making this Cert3ficate of CITV TEL.NO.�'��� W
) Ez,...ption, you should become subject to the Workers' LAWN SPRINKLER SVSTEM - STATE y Y2 LIC. �`� Z �
Compensation provisions of the Lebor Code,you must forth• / yyqTER HEATER � LICENSE NO.�/ ,�p C
�'vith comply wifh such provisions or thfs permit shall ba —
leemed revoked. � " GAS SYSTEM�OUTLETS � DISTRICT NO. PR ESSED BV �
' LiCENSED CONTRACTORS DECLARA'f10N OUTLETS OVER
I hereby atfrcm that 1 am Ilcensed under provisions of Chapter 5 VER SVSTEM
9 (commencing with Section 7000)ot Diviainn 3 of Ihe Buai• � �J � p� DATE yr'✓���j VALIDATION
ness and Protessions Code,and my license is in full force and �
eftect. %
�-j�j FINAL �'j 4'�•' .
Lianse Number �`✓� LiC-CIasS � �� BY �'^ �n (� ��j';
Contracto���e�J�eh� Date�G —�-0�'� � tk�'7��'''J .�
� I am exempt from t licensing requiremenis as I am a Plan check fee � -
licensed architect or e registered profeasional engineer pWMBING PERMIT ISSUING FEE S � ' 1 0 b 5 0 �����'
� acting 3n my�prbfessional capadty(Section 7051, Bus• �-_
iness and Pro(essio�9 Code). TOTAL FEE � � , G���� ����'
Lic,or ReH.No. Date Pla�check app�icant � � � I Q 2 2—H 2 �
HOME OWNER-BUIL�ER DECLARATION Nems . . � �
)[ h -W-affvm that 1 am exempt irom the Contractor's Addrees � ,
Lic: Jl.aw for ihe fotlowing reason(Section.7031.5,Busi• City � - Tel.Nm � � - � , � � �
ness and Professions Code): " �
� 1,as owner of the property,am exclusively contracNng � � � � � �
with licensed contractors to construct the project -
(Section 7044,Business and Profasions Code). . . . . - - -- � � �� � - - �
CONSTRUCTION LENDING AGENCY . - - .. �� �- -- - � - -
i hereby affvm that there is a construction lending agency �
for the performance of the work for which this permit is . . _ . . �
issued(Sec.3097,Civ.C.). �
LendePs Name ' . " - .
LendePs Addrcss � �
I certity ibat I have reed thi4 application and state that the
above information is correct.I agree to comply with ali County SEE REVERSE POR ERPLANATORY LANGUAGE - - ��� - � - � � -
ordinances and State Iaws regutating Plumbing, and hereby . .
authorize reprexnfatives of ihis Counly to enter upon the
a ove-mentioned Dr erty for inspection purposea � � � �� , � � . � �
/d—� �Y
SiQnature o(Parmittee Date .
i _ _ __ _-- - -- - - _ .
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