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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 _ _ __ _-- - -- - - _ . . � � � _ _ �' � c� � x � c� � c y Z Z r. oi C � uDi tDi� O 2 � . ,,.��C . .� . { -i m `L < -o L� � D m� m Z D m � S � � Dv - ' � � G� .m Z � N . � - -� � vD � T � '� �' r' r O � �r 0 �� m � ai � ! . ,✓ •:_. '. , � 1 C D � � r < _, _- •-. _� : D �n m m Z p cn _.. — a� ; ._ . r,' C� p cn � G� 9 Z _ : e . � • � * �� . , � n. � m 41 � � , • IT , D O ', - �' -t y _..'� . , � m , � ; � � N , I : . � ' . ��`. . . • - ' N � _ � , � ! C . . '- 3J m . , � ' � � .... . � . . ' Z y � n � 0 i � . . � � z . 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