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HomeMy WebLinkAbout1224A --�'2,g��� %25""�/9' �rt-�a'/� � WORKER3'COMPENSATION DECIARATION APPLIEATI4N FOR PLUMBING PERMIT I here6y,affirm ihat i have a certifiwte of cansem ta self 78q887A � insure,or a roriificote of Workers'Compensation Ins�ranca, CE 817(REV.8/88) . or a cartiHad copy Iherwf l5ec.38W,Lob.C.) � COUNTY OF LOS ANGELES DEPT. qF PUBLIC WORKS 0����=$m��y�'raai✓� Cenified copy is hereby furnished. OFOR APPLICANT TO FIIL IN(PRINT pR TYPE) B���p��''� �f�S Certified copy is filed with the covnty building inspec- Ap�RESS L i �iondeparlme�nl/. /� Nl1MBER FIXTUREORITFM � iEE ��A�ITY Dofe�Z.—(L�APP��Sa�—k�J¢K.�' �"`� WATERCLOSET NEAREST CERTIFICATE OF E7f€MPTION fROM WORKERS' BATH tUB -- CROSS ST. � z � COMPENSATION INSURANCE OWNER (ihl�s�cfion npd not 6�wmpl�t��iF th�wosk tovolr�d br SHoweR fb�pvmil Is tor on�bundr�d dollan(f100)o�I�u.) LnVATORv MAIi �'—"' ADDRESS I cenify that in�he performonce of ihe work fw which this permil is inoed,I shall not employ any perzon in any monner SINR `��' CI7V TEL.NO. so os�o become su6jeti ro�he Workars'Compsnsotion Laws. oiStiwASttER _ GONTRACTOR ."�"e ' Applicanf CLOTHESWASHER ADDRESS �ICE i0 APPIICANT: If, oher making �his CeHificate of SWIMMINGPOOLRECEPTOR Remption, you should become su6ject �o �he Workars' qTy TE�.NO. Compensption provisions of 7he labor Code,you mvsi forth- �AWN SPRINKLER SYSTEM wifh comply with soch provisions or lhis permir sholl be STATE uC. deemed�evoked. WATER HEATER LICENSE NO. CLA55 LIC€NSFO CONTRACTORS DECLRRATION �I$,7RICT NO, vROCE55ED BY � i Mereby affirm that I am licansed under provisions of Chdpfe�9 GAS SYSTEM OUTLETS '1 D I�(y� �� y�. (commancing wi�h Setlian 70f70)of Division 3 of the Business OUTLET50VER � � �1 �C and Professions Code,and m li nse is in full forcef�d e 5 PER SYSTEM FINAL / VALIDATION LiCense Number� �� Lic.Class ""�� DATE //�'�/'FJ� � ��� ��� FINAL //J b Con[ra<to - te BV ''yYL V ❑ "" W I om axempt under Sea y B.BP.C.for r6�s reasoo plan check fee ► � Dote: `: 1 2 2 u A PLUMBIN6 VERMIT ISSUING FEE E � .Jr Signature r;� o • . • TOTAL FEE � 1a �7�50 Plan check opplicant SINGLE fAMIIY R , a%(j 5O� " ' HON1E OWNER-BUILDER DECIARATiON �Name .areby affirm�hat I om exempt from the Contractor'a license - Addrass D�`.`'�� �s 7 , Law for the fo�lowing reason (Settion 7031.5, Busineas and Profesaions Code): City Tei.No. ❑ I,as own�r of fhe property,.will do the wo(k arvd�he siructu�e is no�intended or offmed fo�sale (Section � 7044,Business and P�ofessions Code). � . CONSTRUCTION IENDING AG€NCY . , 1 hereby aff�rm tho��here Is a construction Isndir�agency for rhe performonce of ths work for which this permit ie issued (Sec.�97,Civ.C.} � �...ea.r ke�tlMs Atfdl�u.--.._— I certify that 1 have reod this application and swte that the � above informolion is mrrect.I ogree lo tomply with all CouMy or�inoncez ond Stote lows regulo�ing Glumbing,ond hareby o horize repr senlaiivas a��his Counly ta eMer upan�he a ve- emio ed o for' ti purpase:. SEE REVERSE FOR EXPLANA70RY LANGUAGE i �. S�gnat �e o� ar it�e te --�» _ . r . . - + . ` - � + �� � - �� � '�ti . A����i ' ' � ��i ' �l �1; '\ i '�a'� ' _ -, .. __' _'. .._... . _ -__ � ____� . .__..... r.... . . ... .� - , - k � � �� aP �ln �,`. I ,'f b 5 '.TU ._ _.__ . �._.._ __` _'____. . __` ,.__ � • � LI r�-if1r _.____ 1nC RS a W c �!_.. �7►" � ...�6�� . {� '- -.-,�r-._. �IN FC i f.�f�('li ___ ._...-.. I� .�... I � ( , I I I. L �� . .c.��. FO CFI P ll�.�.h.,, � � ,` . � ... i f ]t)77 . Ac P�.?�'JC - . . 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