HomeMy WebLinkAbout1036 S COGBURN LN --.-��.�.�, �____._ _._--_�-�
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WORKERS COMPENSA710N OECLARATION A�p��������A� �O�i���IY��i�� ilY��i
� ��!hereby aff...r.that i hove n tertificoie oi carisenr to self �7,yt�i;.p .
�insure,or a tertifimte of Workers'Compenwtion Insurance, CE&17(REy.ip/81) �
or o ca�tiiied capy thereoff�(S+�.3800,lab.�C.)� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Poli o �'t?4�Z`onfpony �^jo S'/�sG/��'1.. . . . .
: Certified copy is hereby fumished. 0 !
: ❑ . - FOR APPLiCANTTO FILt IN�PRINT OR TYPE1 BUILDING � l - �
Certified copy is filed wilh the c ui i g inspec- ADDRESS �3 � N r
tion departmenl. ' NUMBER FI%TURE OR I7EM
(@� FEE IOUlI7Y � f7. � � �1
� DoIeJ�Applicani� WA7ERCLOSET � NEAREST -
� � CROSS ST.
� CERTIFICAIE OP EXEMPT�ON FROM WORKERS' eATH TUB -
COMPENSATION INSURANCE SHOWER OWNER � '
(Thl�secelon need no►be eomplNad if ths srork Inwlved by t r �
tha parmlt Is for on�hu�idrod dollan(5100)or les3.) tAVATORY aDDRE55 V�� C �r �
I certify thaf in the performonce of 1he work for which�hrs
� permit is issued,I shall not employ any person in any manne� SMK� Ci �4 TEL NO. �
so as fo betome subjeci to the.Workers'Compensation Laws. DiSHWASHER
COMRACTO
Dafe Applicont - - � - C10THES WASFIER ADO4ES5 - -
NOTICE f0 APPI.iCANR If, ofYer makin� rhis Ca���fim?e of .. � � �
�-�- ��fxe�m�SNors;�you�sho�ld becbme�iubject io the Workers' � �jM�"����'���� -
Compensafio�pravilions of 1{�e Labor Code,you mu4t fOrth- �AWN SPRINKIER SYSTFM . C' �`��� �/�r
wiih comply wifh such provisions or dhis permN sholl br. STA7E . UC.
� deemed revoked. . WATER HEATER � UCENSE NO. C1A55 ... .. _..... .
R. LICENSED CDNTRACTORS DECt,ARqTIDN_ ...... .. . � � �iSTRiCT n10. pq�CE SSeD er
� � ��1 hereby affirm�hot I am�icensed onderprovisions of Chopter 9 Gn55YSiEM OURE75 (�\�\j . ,
(commencSng with Section 7000)of Dioision 3 of the Business � OU71E?SOveR � O '-1� y
and Professions Code,and my license is in full force and eNect. 5 PER SYSTeM flNA � � VALIDATION �
� iicense Numbe L'+c.Class_.,�.__ DATE�r�7 �S V
Conh6�o���l��a�d �/�1�� FINA �
BY - Q
w
❑ F am exempt under Sea - � . � - � a,
+ .. ...._....__... Vj
B.BP.C.forthis�eason . . ._ _ ..._. . . .._.... . . .. � .._._ . .:._..._ ,...__ ..___ .. . z ..
___ _ PTan check fee
� � Do'e. . � . . . ...... �
. . _._. . . ..
- � �� � � . . ..�.. . PIUMSING PERMIT ISSUING FEf$ • '`�` _ .. . . . ...
� � SignaWre . , . . . __. . ... . . , . .......... .. . .. .
( ... ... - . ...,._. . ..
..�. ..,.. .. .. .. . .. TO7Ai PEE� .
� . _ , . . . Plan th«k np�+I�r.ont � . . . . � �
SiNGie FAMIIY � �'
HOME OWNFR-BUILDER DECLARATION � Name `1 ���F
i �i Mereby otfirm that I am exempt from the Contracror a License , p�ress
I Law for�he�foBowing reason�Sedion 7W1.5,Business ond � e 5
- Professions Code: . n• ' ' •
. a ) , City Tel.No. � � .
1,as owner ofi rhe property,wi�l do�he work and the f • �3�l 5(� .
structore is not intended or offered for sale(Section
7044,8usiness and Prafessions Code. . � ' _ �
� . • •ae5o�
CONSTRUCTION IENDING AGENCY � . . -� � � �� '
_ u7.i7-85
_..
I hereby aFfirm thot fhere is o mnstruction lending agency 4a - - --� �- -� � � �� � ��
� -tha performance of the work for whith this permit is issued . . . - �,
�Set.3097.Civ.t.).
Lender's fdame �
lender i Addrass � � -
I certify ihat I have read�his application ond s�ate fhat the ►
obove i rmation is mrrect.1 agree lo comply with all Counry .
ordi nc and Sl�fe law egulafing Plumbing,and hereby
au orize pr eAfativ s f lhis Coumy to enrer upon the - �
ave- io d pr m for inspedion purposes. � .
U/ SEE REVER5E fOR EXPLANATORY LANGUAGE
7'��A\r�
ignaWre of Permiftee Dafa ,
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