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HomeMy WebLinkAbout1222A 6"4PPLICATION FO�UM�ING PERM��� � WORKERS'COMVENSATION D€CLARATION � 1 hereby,affirm thar I have a certificote ot consenr io selt 76A667A insure,or o certifimte of Workers'Compensation Insuronce, CE 817(REV.8/B8) � or a cer�ified co y thereof ec.3800� .. Pnolicy ompany ��' COUNTY �F LOS ANCiELES DEPT. OF FUBLICr W4[iKS �J Ceriifled copy Is hereby furnished. FOR APPIICANT TO FILI IN(PRINT OR NPE) BUIIDiNC /'S .�(,/I�� � Cerrified capy is filed with the county building inspec- ADDRE55 �•�� �r ti depnrtment }¢" NUMBER FIXTUREORITEM � FEE ��A`�T� � ' Dale_�AppliSanl ������'!'-'' � WAiERGLOSET NEANEST w�� �. BATH)Ue --. CRO55 S �v CERTIFlCATE OF EXEMPTION FROM WORKERS' . COMPENSATION INSURANCE SHOwER OWNER (Tbis s�ction nNd net M eomplN�d if IM work Imrolwd by th�p�rm3e is for on�hu�dnd dollan(;fOU)or lesc.) �qvAiORY MAII ADDRE55 I cerrify�hof in rhe performonce of the work for which Ihis permir is issued,I sholl no�employ any pe+son in ony monner SINK � CiTV O N TEL.N0. �j so as to become subject 10�he Wo�kers'Compensotion Lows. DISHWASH[R � CONTRAC70R ' applimnf CLOTHES WASHER qDDRE55 �' �y.� ^�ICE TO APPLICANT: If, ofier moking �hls Certificate of " SWIMMINGPOOLRE[EP70R �� � �` �semptian, you should bemme subjecf fo �he Workers' CITY Y.�/�- �4. � � Compensafion pro�isions of fhe Labor Code,you most forth- �,qWNSPRINKLER5V5TEM y inc �omply th such provisions or this permit sholl be STATE LIC. rF fleemed r0vo{�ed. WATER HEATER IICFNSE NO.. � QASN�-J�. UCENSE�C4NTRACTORS DECIARATION DiSiRICi NO. PROCE55 BV I hereby affirm rhol I om licensed undr provisions of Chopler 9 6A5 SYSTEM OUTLETS ��y/�� f (mmmencing wi�h Seeiion 7000)of Division 3 of ihe Business � OUTlEt50vER O " 'Q` � � ond Grofessions Code,and my license is in full force ond effecL 5 PER SVSTEM FINAI 2 /��y�..�7 DATE f i� �9� VAtIDATION V 4icense Numbe��^'d Lic Closs�_ � FINAL ,�J //� � Controc�o� Dotej�_=yy�� BY //�`�{' V ❑ � I om exempt under Sec. � B.BP.C.for this reason � Plan check fee ► � Date: `"� �2,L a PLUMBING PERMIT ISSUING FEE S d si9oo,ure �, u • • • �5 TOTAt FEE ( Plan check applimnt ' � c 7��� � SINGIE FAMILY , , ; ��;;v�,x � HOME OWNER-BUIL�ER DEtLARATION Name mro6y affirm�hat I am axempt fram ihe Coniractor's Licensa qddrass ��:`��`8 7 _ Low for�the following reason(Section 7031.5, Business and Wofessions Code): City Tel.No. ❑ �,as owner of ihe properfy,will do the work ond�he structure is not in�ended or offered fo�sale(Section � 7D44,Business ond Professions Code). CONSiRUCiION IENDING AGENCY I hereby affirm that thero Is a consnucHon IanQirg agancy fw ihe periormanca of�he work#or which this permil is issued (Scc.3647,Civ.C.). � kem('es,t Rltrrn�_ . LaM1Cr'sf4ddC4tS -- ' I cartify that I have read this applim�ion ond state thot ihe ► above infwmation is corract.I ogree�o comply with all County rdinances ond State laws ragulating Plumbing,and hereby �fhorize�epreseNofives of this Caun�y ro enter upon�he o�e-msmirn J pr�n r spe ti urposea. SEE REVERSE FOR EXPLANATORY LANGUAGE i � �� Signature of Permi te _ _-- ' _ —__ - r , � � - � �, � _. - � - ...� r . _ .. - . i .. . • _. , - . �'� '. � �i . . F . , a ,*k ' . 'J� y �,1, . . . .. . . ., . r— _"'_ .__. —"' _.. �__ "___ ^/if i�'� O Il�^ fl � I� E 10 (`OE.; - "' `.'l. . �: L l .��� AF A 5 x ..__. . .______ . . ur��ec s n �o r �Jj�1 � J a � ______ .— 1l'��/�� _�- ,� . . . . . .. `I�rr rf I _ ' -..� ..3r,r5. �kOJGH P l. I'�.. 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