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HomeMy WebLinkAbout1230A "�'fRf��""� L��N ,�'C6NIiEW&4110N DKLARAT70N APPLICATION FOR P U B G PERMIT�a� I hereby,affirm that I have a certifimte of consenf to self 76A687A � insure,or a certificate of Workers'Compensarion Insurance, CE 817(flEV.B/88) or o Certified mpy tharoof(Sec.3800,Lob.C.) �)���-�� c" I COUNTY dF LOS ANQELE& DEPT:OF:QUBLIG�,WORKS P�olicy No. ompanyv� Y-�' �L/'f_ � , .. �', � ,� Ceriifiad copy is hereby furnisbed. � � . FOR APPIICANT TO Fltl IN(PRINT OR TYPE) BUILDING A �r �a.r _,.�C� Certified copy is filed wiih�he county buiiding inspec- ADDRE55 V /\I/ / U`-� - [�• iion departmenf. NUMBER FIMVRF OR ITEM � FEE LOCALITY .,��> Date � ��'�J � APPI1San� 1 i=.v ,'�, WAffRCLOSET � NEAREST CERTIFICAiE OF EXEMPTION FROM WORKERS' BATH TUB � �� CROSS St. / COMQ€NSAiION INSURANCE SHOWER OWNER � ' (Thie ucNen n��d not M compl�t�d if th�work irtvolwd by MAI� fM p�rmit ts For on�h�ndnd dollan(5100)or les�.) inVAtORv � �'�j q00RESS I certify ihat in the performance of�he work for which+his permit is issued,I sholl not employ ony person in any manner SMx �j Ci1Y CQ4���n L. so os�o become subiect�o�he Workers'Compensotion Lows. 1 p15HWA5H£R ( - L�� CONTRACTOQ t`�� �' ^ ,�^te � Applicon� � CLO7HESWASHER f1[,1 . ' iICE TO APPIICANT: If, atrer moking ihis Cerfifimra of ADORE55 � � , �..emption, you should become su6ject to the Workers' SWIMMINGPOOLRECEPTOR +� Compenwtion provisions of ihe lobo�Co(le,you must forth- �qyyN SPRINKLER SYSTEM ��TY ��{��4��`" � �'T r winc �omply wi�h such provisions o� this permit shall be SinTE �IC. deemed re�oked, WATER HEATER p'� ��CENSF NO. �'' ClASS � n+ UCENSFD CONiRAC70R5 DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm ihpf I am licensed�nder provisians of Chopter 9 GA55YS7EM OU7LETS �� � (commencing wi+h Section 7000)of Division 3 of Ihe Business OUitE750VER . ��� ��1��� � and Professions Codc,ond my license is in full fo�ce and effect 5 PER SYSTEM FINAL ��. �.�� VAUDATION V �� 1 DAiE I license Number ��„��_����i �ic.Closs �-'� OC '`'� ����"��, /� K, FINAL �y O Conkactor�s'1.i'.[1.p�,,.J`�Date)"7_.��,�.—�cZ BY //c V ❑ 1 am exemp�under Sec y 8,8P.C.fa�his reason Plan check fee . � �'.'1 2 Z,0 F � oare: a a � .5 PWMSWG PERMIT ISSUING FEE 5 ; �j �`` Signature TOTAL FEf �'� � �' °1 C�•5� Plan check applicant r, � .� %i�:�('u ��� SINGLE fAh51LV ' HOME OWNER-BUILDER DECLARATION Nome . (�t;�� ��J j sreby offirm thot I am exempt from the Coniracta'a Ucense Addross � . Law for.the following roaso�(Section 7031,5, Busineas and Professions Cade): �i�y Tel.No. ❑ �,as owoer of rhe proparry,will do the work and�he , sirod�ro is not interided or offered for sala(Sedion � 7044,Busineu arid Prof�aie,ra Code). CONSTRUCTION LENDING AGENCV . . I he.eby affirm thar there Is a consh�ction lendirrg ogency for � - iMe performonce of ths wrork ior whicb�his permit is iseued (See 304T,Civ.C.). Y@�t EfD��m�wns. . Lendnr'yAtpileg� -- _ I c�r�fy thot 1 have reod lhis opplication and state thot Ihe . a ve informatioe ia carect.I agree to comply witk all County or nances and S�ata laws regulating Plum6ing,and hereby - au orize repre raf� s r i � un f e ier upon the a �9- nti r na Ct' n �,�)�sy� SEE REVERSE POR EXPLANAtORY LANGUAGE 3 a Signo�ure of Permiftep �afe �. _ ��—- — _ --� �` `+�+�-—g y.— - , . . . . • � _. � -� i � _ , . � � � . ' . 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