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HomeMy WebLinkAbout1231A '77��Icr�. yr2�"�'7 ��- • WORKERS'COMPENSAiIONDECtARATION /�ppLICATION FOR PLUMBING PERMI� I hereby,affirm thot I have a certifimte of consent to self 78A887A � imore,or a certificate of Workers'Campensafion Insurance, CE 817(REV.8/88� or o cer�ified topy thercof(Sec.3800,Lob. ) OCY NQ�'���f,���Y�,�..� � � � GOUNTY OF LOS ANGELES DEP.T.�OF'�PUBLIC 1W�BKS Cenified copy is he eby fumished. ,~` , � FOR APPLICAM TO FILI IN(PRINT OR TVPE) BUILpING fi�t i �G i�9� � Certified copy is filed with ihe tounty buildinq inspeo ADDRESS /�/7 ✓ [qL.Ic� iion dep/atlmenl. NUMBER FIXTURE OR ITEM � FEE ����TY ���� Dpte���L��j� AppliqaM` �'�'LY' WATERCLOSET � " NEAR[ST CERTIFICATE OF EX€MPTION FROM WORKERS' BATH iUB � �` CROSS ST. n� �F� COMPENSATION INSURANCE SHOwER OWNER � (Tbis sacfion�ed nof b�complN�d if the work inrolvod by MAIL Hro permf�Is fer on�hundred dolbr�(S70Q)or I�aa.) tnVniORY �iC� a�OR€55 I<e.�ify rhat in the parformanca of the work for which ihis permit is issued,I shall nof employ any parsan in any manner SINK � =�j CITY � ��n .NO so as to bacome subjecl fo Ihe Workers'Compensatian Laws. pI5HWA5HE2 . . � ./f�Tj CONTRACTOR . _���� �rn, �Y , ���.e Applicanl Cl07HE5 WRSHER � (�V qpDRE55 lCE i0 APPLICANT: If, after making ihis Certificate of SWIMMINGPOOIRECEVTOR a.amption, you should 6emme subjec� �o ihe Workers' Compensation provisians of fhe Labor Code,yo�mu51 forth-; LAWNSPRINKLERSYSTEM CITV �.� O. � with comply wi�h such provisions or this parmit sholl be STATE L�C. deemed revoked. WATER HEAiER UCENSE NO. � � CLA55 � LICENSED CONTRACTORS DECLARATION � � DISTRICT NO. PROCESSEQ B I heraby affirm ihm I am ticensed under provisions of Chapter 9 GAS SYSTEM OUTLEis �1`p �/y,� (rommencing wi�h$ectian 7000)of Division 3 of the Bosiness OUTLETSOVER �•� '�' >' and Professions Code,and my license is in fall force and affecl. 5 PER SYS7EM FDIAN EL VALIpATION � `3 t3D�� l��.v/Fr� Litense Number � Lic.Closs� � ���n FINAL /�� � Contractor �� �Date_.S1 ��' I..� BY °'""'" v � W I am exempr under Sea �g, � 6.&P.C.for this reason p�an check fee \ -�� 1 �3,1 A ? Da�e: pLUM81NG PERMIT ISSUING FEE$ � ', ., � ° " ' 'b Signafure TOTAL FEE . � �:� ��7 E,v� . Plan check applimM �. .. ,. � -�����,� � SINGLE fAMILY �� ` � HOME OWNER-BUILDER DECLARA710N Name �. .r,-_. � �.�7 _re6y affirm that I am exemp�from Ihe Contradw's Licenae Addross . Law for�the following reason(Section 7031.5, Bosiness ond Professions Code): City Tel.No. � ❑ I,as owner of�he property,.will do rhe work and�he � . slructure is not intendad or offared for sale (Section 7044,Busi�ass and P�ofeasions Code). CONSTRUCTION IENDlNG AGENCY � � I hereby affirm thot there Is a conatrucNon lending agancy for Ihe perfo�mance of the work for which this permit is issued (5ee.3IIA7,Cir.G.). - hcmfter510tlrfse tandbr's Flttdreas � I certify that I have read fhis applicotion and stale that the � above information is correct.I agrae�o comply with oll County � inances and Stote laws regulating Piumbing,ond hereby Ihorizs representoliv f is Cou y a anter upon Ihe ova eniio t f in a- urp�^� ��, / .;/ SEE REVERSE FOR EXPkANATORY 4ANGUA6E Signcwre-of Parmittas Oa1e , � � i i ti _ � , _ _ . . . �?�-�.ti�� , .. � ��1 �a ��� � . y� i -,a� � � - • aV .1 � � �� - - • _.._ . -_-- '._ __ _�._ --- � F eo�u ._.._ r-- -cru c � r; � r rn: �o e'� _ �_.- i.r � — __ _.... ..' _._ _'__'_ . . L F i UNDE F2 V ORI. f{ � � � � � ' � ' � RO.I�-f FILI";'.I .; , ! ���1- � . .._��__' .� __. ... .___ '__._ ___ .... .__._ .."_"_ t.� . 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