Loading...
HomeMy WebLinkAbout1223A _ WORKERS'COMPENSATIONDECLARATION � APPUCATlV�� � VR �LL�Y�B�1�G9PERM1, � � I hereby,afiirm thor I have a certificate of consent to self 78A867A � insure,oi a carlificote of Workers'Campensafion Insurance, CE 817(REV.8/88) or o ceriified copy ther f(Sec.3800,Lob.C.) � Q�Y�E J���omPa��'����7 COUNTY OF LOS ANGELES UEPT: OF PUBIIC WORKS Ceitified mpy is here6y fumished. ❑ FOR APPUCANT TO FILL IN(PRINT OR TVVE� BUIL�ING Cerfified copy is filed with fhe county building inspec- ADDRESS tion(lepo�finent. NUMBER FIXTURE OR ITEM � FEE 40CALI7V .�� l� WATER CLOSET pote� �� AppliSo '�* NEAREST CERTIFICATE OF EXEMpTION�FROM WORKERS' B/+THTUB --- Ce055 / COMPENSA710N INSURANCE pWNER � (This s�Nion nwd aoe M compl�Nd if Ib�work inralr�d 6y SriOwes fh�p�rmiT ts for ono hu�nd dollan(SI00)or b�s.) tAvniORY � � MAn _ '�— ADDRE55 I certify that in the performonce of ihe wark for which ihis � permii is issued,I sholl noi employ any person in pny manner SINK –'� CI7Y + TE. so as ro became subject to the Workars'Compensation Laws. � / DISHWASHER --"' CONTRACTOR �� rscN�/L i � ,Dnte Applimnl CLO7HE5 WASHER ADDRf55 'ICE TO APPUCANT: If, afler making fhis Cerfifimte of v � � _�mprion, you should become subjec+ fo fhe Workeri 1 SWIMMiNGPOOLRfCEPTOR �,.Xf.r�l�rf.,,y,b� /� _ Compensotion provisions of the Labor Code,yoo must forth- lAWNSPRtNKLER5V5TEM C'TM "" """� ��"'� wi�h comply wilh such provisio�s or ihis parmil shall be ` STATE y� '} UC. deemed revoked. � WqTER HEATER UCENSE NO. �� {,/ ..7 Clq$5 UCENSED CONTRACTOWS�KLARATION . DISTRICi NO. ry�PROCESSED BY I hereby affirm thaf I am lice�sed u�der provisions of Chopfer 9 GAS SVSTEM OUTlE75 p 1 ,` �o n (mmmencing wi+h Sedion 7000)of Division 3 of the Business OUTlET50vER � ond Professions C e,ond my license is in fu��fo/iq/p pnd effecf. 5 PER SYSTEM FDIAN EL � $„!/ VALIDATION � Licensa Numbe�/�d Lic.Ga53�'� �� a � FINAL � '�y ��y�,r ry�/ C Contrac��"��U/tF-+Date� gY /��'i,� V ❑ f�� Y! I am exempt under Sec. a 45 B.BP.C.for rhis reason Plan check fee - \ � DO1e� PIUMBING PERMIT ISSUING FfE$ ` � :'_"�1 ?2 3 A Signature TOTAL FEE f i.� • ° • •5 . Pian check applicanr f �- ��7 u4,5� ' SINGLE FAMILY � � HOME OWNER-BUlLDER DECLARATION Name r, •, '-��4.,��� �eby oNirm thpt 1 am exempt from the Controdor'e license � qddress . law far-ihe following reason(Section 7031.5,Buslness ond 0�:.�j� ��j'� Professions Code�: City Tel.No. ❑ I,as owner of fhe property,.will do the work ond�hs , etructure is not inte�ad or offered for sale (Senion 70d4,Business and Prafessions Codej. CONSTRUCTION LENDING AGENCY � I here6y offirm�haf there is a conatruction lending agmncy far Ihe performonce of the work for whith fhis permit Is iswed (Ssc.309T,Civ.C.). � � - kdDk(�mfilNlYln - . Le�Bda A1dtlll7 I certify rfwt I have read�his applicarion aad siote fhvf ihe � o ve iniormation is corrac�.I ogree to mmply with all County o inancas and Stafe laws regulafing Flumbing,ond hereby a hor:ze repr semotives o �his Cou io en�er upon the o ave- entio ed t -or" �pur n. �3�� SEE RBVERSE FOR EXPlANATORY LANGUAGE S� ature o ermiNee Dare t – - – �� �-- - __ _ _ .o_.. ._ _ _ . . . .. _ . _. . . . �- i �� �t _� ;_ i ,, „ - .4' ' l,' ! v ' • � T �4 . �1� t �-� � _.._ .� _�__ _�__ AP �'At5 � i_ �__ � INS �CT6R'S tOTto . �. � . I� f p '� U F I� . ._ __ __. _._. .___ —_.Y _..___— �_ UNOEIi lF� 1�ORK � B � ' . . r.: �. l S I tTll Ft U H P�U �vG . . . � .. � __ _.__ .,._'_ _— _.___.— . _ ..— � l . I � t f I :� ' . tC :31�' ,� '—_ � . Gn5 C:� . . � � _._.._ __._— __._. _ __ ' F fi C. � ty r .��n 4 1 � F .z_ ..__— . ...._'__ "'. .._ __ '.._ __.__ __"" _� r'. [.. 1 f .f . �. I - c� I h. CAS VEF,7 I .. : . . � ' � .- �-.� ..._ _ �.__ .._'___.._. � . . . . -� . r�c a y ����, F� .r r !o hOT Wh1E.FeATGdi� � -� ' , .__ _—__ —______— -______—�._ ___'..-. � � . � ._____^_—._. _—___'__"_._�_____. ._.__" . ... G�:�est��owp :.-.n 9vsuchprri��rt�.;f�leu5irnsdsrare. Fiuv3fwGFltTucsS ..�, � . .�. � _ _. .. . . . . . � . nr�i f 1::.s ip .� �. i�.p�a , �frh� '_—_�.. � _.: �, _��. jy ;_. -.... __,_ ___" . ______ .. ' _.�___ .. . ` , cnsTeer � �"�3, . _.._ ._. r rr< � � r�r<, r s ,.,n���„.iw,t, — -- _.�;- - , s r':��o � � ,:09 r� r,�s�o��o.,d P�af�. UTfLITYf.O.hJll ED . _. � -- --- .—.._. �.`_�_ __�._ _ _— ._._ . — _. _t ..: . _--'. . . . . . . _ c ir:C rh.t 1' ��..�+rT�th��n#� f fne Ncsis � --- � -= 1 _ _. __ � , � �•, � � �, , � t 5���o„ _____^_�-- ---------- Fi�,a: r� ,.� �.,,,.f , �a:3ist �,; �r, �,F � r ,r.:��Pi� ---'•-----�---- -----'--.___. _.. ---- `-- --- -- c r t ic � (<�. t� � rn ; rh f ��. f nd�ecl ---—_ i ..__'r_'._ . .�_ . .._ d 1 � { � . . _ ,_ NDJ TRl4. - ' -'� �.• . . . .-. . . ]I c .� 1} p , �II d F � k,r,nd �^A57[ ... . . _. _..__`_____— ____ . _...__._'_— ____�_.r.�. ' � �_...�....i;�-+�--��s�-++at+u...x__.....:��._..r. . . . . . _!r I ' 1 i.,� 'O ..�{. �I�� •-� - � . (S+.cin: Fu.ein....,br..��.ol.,;..;n,C�..l�: ThcC� z� -. . ,�� . . .._._._._'.__._ '- __._'______._._..__ ._..____.._.—. __'_ �� . .. , . . ._ . .. . . . . _ �...'sii :L�..,c � 7.,;Ift , . �p oporty , .' . . . .. e.F.c k (�� o i�,��, � . h.:�r . e..-�.J v, .. d;, s ueh . . ' . . , _. ______.._. _:_... .___ .. _ ._...__.._'___-_�_—._:__ ' . . ��. ' . + . %. . ; - ... . �r,:'`,hir�-.,:❑f,.•ov d_r I�:n!s�1 im,,rcvwns�ds ares nof .' . ..... � .. . � .- .. . � __. ._.. - ; . int��,^irl.t!�.�if:,�e:l f.rr s<as.1(,f;cww��;thc tuildinn or _. ..._.._____ . _ ______—__.__. ____—.._______--______ i -- ��Fa'ov : f . .nl w. "in on y� , of co r, I on:the � : _,' .'�'- . .r �, . '. . . � ''- . awirrrb., :�v.rllr�.,�.plinrturJ.:,.ofp-cvT,yl�,s�hedid �'. . . . . .. _._.__ ____. __.—__— .__'____._�____—___ . fr,,t:� f ssfr.; . . . .--.. .. ., . .. . .. . . . . . . rvat t:yylF cr I��K•:�•.ri -Frarp.iw c �� . __ . ..___._. ' -__._.._ ._—______ . ___ _—'___ ._ . :... _. ., . .. . .. . . . . ._ . . .. _ .. - �I�C'il�� -:I��;)tV1�t.ti1�C.�_'___—_— . . ' .'_-_._.._..._ _"'..__._ .._..-.,. -____._ .._.___ .._-__._ .. . .. . .. . � . E F(S 1 1�:'Ihl:�f :]:",'JIl_._.._..__""—_.__'—___ �. _._" .-____ '"_._._ __."_"_ �. ... . _._.�_ ."_." _—'._ --_"� � , _ ' _ - --. _... _----- r���:;_ _-- . . -. . _ �'_._--._ ..___ �`�_.__ __... ... ___..__,_..__�_- Ov.n.zr .._..----'-- ------- ---_. __..._._.._._. __ . ., . . , ' INSFECTOE'S N71i5 _ . . . -_. -_.. _ . ' � . , . ----------- ..__.,_._... --_._.._.__..__ s....__._--- -----------------------------�- � . � . 1 —.— -----------��-----._._.� _. _...____ - `--------------------------------__ . .. . . ._ . . , . �