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HomeMy WebLinkAbout12_16_1989 - 2016 PEACEFUL HILLS RD �i�s �: � �9 -' �WORKERS'COMPENSATIONDECLARATION � �APPLICATION FOR-PLU�� I � 6 g,p� � I hereby,aHirmyho�I have�a certifi�me of consent to self in- ���2'ADaw aiB7 � 5ure,ar o cer�lf�ttlt o(Workers'Compensation Insurance,or a CE 817(REV.�B/86) � - - � � � � S��M!\ ceitlRed copy ihereof(Sec:3800,lob:C.) � - V/-'t Policy No. Company L� /� - COUNTY OF LOS ANGELES DEPT.O B I R 5 ���Ce�tified copy is hereby furnished. � , , � . � � BuiLDiNG / � �� � -FOR APPIICANT TO FILL IN(PRINT OR TYPE) AODRE55 O��j � ���5 � �Certified copy is filed'with the county building inspection � � � department. . �- _ NUMBER FIXTURE OR I7EM @ FEE ��A��TY � . � � � � WATER CLOSET(TOILET)� - � ���/��� - Dofe� ' � � -ApplicaM � � - NEAREST. . � �� �' CERTIFICATE OF EXEMPTION FROM WORKERS' � eniH TUa. CROSS ST. - -, .;�,COMPENSATIONINSURANCE . � � � SHOwER � - - OWNER�. . - -- . (This soction need not 6e complated if fha work Inra�wd 6y ,Hp,i� . - _ ihs Farm�l is for one hvedrsd dollan(S100J or Isss.)� �� � LnVntOrtr- � � � � nDDeEss � � � � � I certify thal in the performance�of the work tor which ihis per- . SiNK � � Ciiv -� - �� 7EL n10. � � - - mit is issoed,I sholl nof employ ony person in any monner so � , . osYo become sv6jett to Ihe Workeri Compensotion laws. � - DISHWASHER - . � � � . . . . , , . . CONTRACTOR �C ��`�� . . Doie � ' -APPIitOnt � . . � . . � CLOTHE5 WASHER A�DRESS � �lF-i- ' . NOTICE TO APPUCANT:I(,ofler moking ih s Certifimre of Ex• -- � Syy���NG POOL RECEPTOR � � � . emption;you should become sub�eU fo the Workeri Compen- CITV J TEI.N���� � solion provisions o/ihe Lobor Code,you musf forthwith comp- � �,qyyN SPRINKLER SvSTEM � � - �� � ly wifh soch provisions or this permi�shall be deemed revok- SinTE � � . . � ed. ' - � � , , �� WATER HFATER � LiCENSE NO � .% J CLASS � ��� � �� .UCENSED CONTRACTORS DECLARATION � . DiS7eiCs-qi0. . a20C D BY . . I hereby affirm thot 1 om litensed under provisions of Chapter G.45 SYSiEM OUTLETS � �—` 9(tommencing wi�h Sedion 7000)of Division 3 of ihe Business , OUTLE75 OVEk� � and Professions Code;and my license is in full force and ei- 5 PE SY TEM. � FINAL VALIDATION r fect. .� � �l - �/� . � � DATE ' �' � � ` p `,on ro or mber�,7 �3/`J��ic.Closs�> . . V �f �j[��� E/f/T- BY A� O . /' � �N'" " �, � Date "� . . . F. . � I om�exempt under Set. . ' � - ' _ W �- _ a e.aP.c,fo� ' �eoson plon check fee � _ , x � . PLUM0ING PERMIT ISSUING FEE 5 O � � � , .g i7 7,�A , �� $ignat e - . . . . . 70TAL FEE . . � � . � [� �. .•.. .5 SINGLE FAMILY � Plan check applicant � � OME OWNER-BUILDER DECLARATIO � � � - � . . ., . , I •��� 6.Jr O I her offirm tha�I om evempi from ihe Cantmcfoi s License.__. Name . ..-- --- . .-.._- ... -- - -- -- - -- - -�.-_. .'. --:. -�-_�'�-�� � �.�..�. .. Law or ihe following reason(Section 703L5,Businesr and - �� � - � � S O Professions Code): � - � Address � � . � �.��2�9-8 8 � : � � I,�os owner of the properry,will do the work ond Ihe City � . . ' Tel.No. � �. -� � � structure is no1 intended or ofiered for sale(Seclion 7044, . . . . � . . , . . . . . . . . Business ond Professions CodeJ. � . � � � � � - � � ,. �, � ��CONSTRUCTION IENDING AGENCY � � . � � � ' �' ' � . I hereby affirm Ihot Ihare is a construction lending agency fo� � � � , the periormance of the work,for which�his permit is issued - - �_ - ' _ � - � � - � - � � (Sec.3097,Civi C.)..� � �. � � , � . . ' - - Lender's Name � � . � � . Lender's Address � � � I certify that I have read this applicotion ond staie fhot ihe - - - -- � � ' -� , - - � � � � - a6ove informotion is correct.I agree ro mmply wi�h all Coumy - � � . ordinonces ond Stote lows regulatin Plumbing,and hereby � - � � � � � � � � ��� - , � - � � orixe represenlat" s f ihis nty to enter vpon the . . � . . ab ve•memione er r' ction pu�poses. � . : . . . . _ � . . .. �y � ; SEE REVERSE FOR EXPLANATORY LANGUAGE Signofure of ermitlee � a�e . - � - . � i yo z i a � o a a o z � N i ~ � � � m � � . m� � � m m a m v = y D. .� � D 37 - n -NI Z � Z �p � � .on o � m � Z r b • � , ._ � ; ' �� Z �t 9 � � � � . ..`'� .� � . j{ . O ._ p x 2�n � � 'O - ' o i < ' -1 G D 2 O > ���, ♦. o _ ,� . r ' T 31 "'� L7 31 �yj ti = .� � � . ' m � � � � y -� 'I o S�- —. .� � � � . ; . � - L; � e o ` . 3 —" m — . ` - . � , � �i ., . � � . � � `. 1 . • � � m . � 1 � � ' . � � ���� . � . . ? 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