HomeMy WebLinkAbout144 S PALO CEDRO (2) �" . ��
WORKERs•�o^^�NSAr�oN oE«^R^T�oN qppLICATION FOR PLUMBING PERMIT
1 hereby ohirm ihot I fiove o cen�fiwte of wnxnt lo self ,�yqyy�p -
� inevre,or o eertifica�e of Worken'Compe /ian Insurance, �CE 817(REV.10/BI) - � �
or o cer�i(ied copy thereof(Sec.3800,1� .) tOUNTY OF LOS ANGELES BUILDING AND SAFETY
POolicy No. Compony �. � .
Cartified copy�s beraby fumished. �
OFOR AP%IGWi TO Fql IN(PRtNT OR TVPE) ButlDINQ / _ ;
Certified copy�e flfed w�rh the counry building inspec- ��R�
tion dep0�1men1. NUMBER FIMUREORITEM Q FFE ��,��ry j
DCte . aPP��CaM . . WATERCLOSE� . NFAREST
� CERTIFICATE OP FXFMPIION FROM WORKERS' BATH TUB ���' �
COMP�NSATION INSURANCE � . ��Q - OWniER 1
(This sMlon nNd nof bo complofad fF fh�v�erk Imre►r�d br . ��
the pormN le fer en�kondnd doltan(5100)er lan•) uwntOav ACDRESS
I cMl(y thot in the peTformanee of tha work for whieh fhis .
permir ia iaaed,I ahall ro/rmploy arry pmnon in any manner SINK � GIV iEl.NO.�`�d^�
so aa ro became subjeer ro rhe Workan'Compensafion Lows. p��w0.5HEA '
qorirancroe�
Dare appliwnf - � GOiHESwASHEx � AWRE55 a .
NOTICE TO APPUCANi: if,after making�hia Certificate of y�yuµ�tNGPOOIReCEaroe
Exemption, you should hernme subI'ec� �o the Wwkeri �. - . �y,un/i�o�a �
Compemarion prwisimn af rhe kabor Code,you must forth• ayy��iN�ER Sv57EM � �' :
with compfy with au�+ prorisions or fhii permil ahall be �N��. �/fA �� �+ � •
deemad rovokad. . WAiERFIEAiER . �V�T '
LICENSED GON�RACTORS DECIARAT�ON � OISTRIC►NO. BV
�hereby affirm�ha��am I�censed nnde.pra.�siom ot Gap�x 9 � �s srs7FM ovrtfls a - Y i
(commerrcirg with Secflqn 70pp)of Airisipp 3 of the 9.usiness q1RETg OVER N(,� � 0. i
and Hofessions Code,qd my liceme is in fuli force and effael. S PER SYSTEm DATE��i yA���aT��N � 1
C3I v
licensa Numb � ic.Clcss �
� � FIN ` O �
Contrx�a Dora-�i�/a ,,�.,. � .. . � �
� I am eaemp un er c.� . � y 1
� 8.8P.C.for Ihis reoson . Z {
Plan check fee
Date: PLUM8ING PERMIT ISSUING FEE E � �
Signoture ;
TOTAI fEE
i
� Plan check app{�wn1 ��!7,rJ p �
SINGIE fAMIIV ;
HONIE OWNER-BUILDfR OECIARATION Name � � -
�. .:. .�.5
I hereby affirm�har I am eaempt from ehe Co��mNw's license q�,es ��.• • �i S(1
Law for the following reason j5eaion 7(y31.5,Bv�insss and � nx
Prvfeuiom Code): City �Tel.No. � u" !
❑ �,�.� ��L . I
�,m owner of�he prope.�y,will do+he work and rha
shuNure is nW in�anded ar offerod far wle(Section � � � ,
7044,Business and Rofesslons Code�. �
� CONSTRUCTION IENDING AGENCV . � � � �
I hereby affirm Ilrot there ia a tonsh�dion lending aqency for . - -
�he perfamance of the work for which ihis permir�s issued � �
(Sea 3D97.Civ.C.). � - �
lender's Name . � . . .
lende�'s Addross ry
I certify thol 1 have reod ihis vpplicalion and slate thof the � � , , �
abore infamarion is correcr.I ogree ro compFy with all Co�n�y I
ordlnances ond Srare bws egvlating Mumb+ng,and hereby - , �
aufhorize�eprcsenlaliv a fhis Counly 10 enter upon the '
- above-ment� ad pra rty r inspection purpose7. �
i SEE REVERSE POR EXPLANATORY IANGUAGE �
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