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HomeMy WebLinkAbout1221A -- y`�,�9'-� .z�rT ��"-� a-5' WORKERS'COMPENSATION DECLARATION APPLICATION F�R PL�MBING PERMIT ' I hereby,affirm thot I have a cartifimte of conseN to self 78A667A � insure,or a car�ifimte of Wo�kers'Compenwtion Insuranre, CE 817(REV.8/BB) - or o cartifiacf copy iharsof Sec.3A00 l b.C.) ❑ y Q�. � y '����,��� COUNTY OF LOS ANQELES DEPT. OF PUBLIC WORKS Volic No. o n � � � - , Ce�t�fiad copy is hereby furnished. � � FOR APPLI[ANT TO FILL IN{PRINT OR TYPE) 8�����' �� Cerlified copy�s filed with fhe caunty building inspec- ADDRESS tiandapartmen�. NUMBER F17I'fUREOR�TEM � FEE ��A��TY pote r ~"� Appli4cnf�C�� �� WATERCLOSET NEAkE57 ,�,j /J BATH TU8 CRO55 5T. ,v� �" CERTIFICATE OF EXEMPTION FROM WORKER$' � C1 3 COMPENSATION INSURANCE OWNER �'�V��� (Thls srcfion n��d rro4 M complNed IF th�work involwd by SHOwEk fh�p�rmit ta for on�Aumdr�d doilon�5700)or I�u.) � LAVATORV . ADDRE55 I cerrify ihat in 1he performante of Ihe work fo�which fhis y permit is issued,I sholl nol employ any person in pny monner SwK (;�(,j CITY b ���' . so as to bxome sublect ro fhe Workers'Compensa�ion tpws, OiSHWASHER �,��e-Y,Y_ � _/ {)Z� CONTRACTO y��i����•� �7 � ' Applicpnf CLOTHES WASHER 1�� ADDRE55 � ��� ' (ICE i0 APPtICANT: If, ofter making ihis Certifimte of SWImMiNGPOOLRECEPipR emption, you should bemme subjsct ro Ihe Wwkars' ���� v�,, <� .,ompensotion provisions of fhe Lobor Code,you must forfh- LAWNSPRINKLERSYSTEM wilh comply with such provisions or this parmit shall 6e SiA7E tIC. �r deemed revoked. WATER HEATER LICENSE NO. �� ClASS � UCENSED CONipACTORS DECLARATION DISTRICT NO. PROCESSED BY I here6y affirm Iha1 I am licensed undm provisions of Chapter 9 GAS SYSTEM OUTIETS orj (commencing wi�b Seclian 7000)of Division 3 of the Business OU7LE7S OVER - � �a� 4�. and Profescions Coda,and my licanae is in full force and effecL 5 PER SVSTEM FINAI /.�J VAtICATION V 13/� C�,�(� DATE 9 f ���4'� � Li[anse Number �` `^�� Lia Class ^'���-' FINAL 0 Comranor `��P '� �Dote�ti�.t'�'�� BY 4 � a I am exempt under Sec. � B.BP.C.for lhis reoson , z Plan check fee i'1 2 2,1 A � Oote: PWM&ING PERMIT ISSUING FEE¢ Signafure � �� f:a e s • !,�j � TOTALfEE � � Dlan check applkant � � ��°���5 0 � � � � SINGLE FAMI4Y HOME OWNER-BUILDER DECLARATION Name ` �� ' '-�-5 C�' �eby o+firm thaf I am ezempt from�hs Contractor's license .Address � 0�,�� —8� ,�for�the following reawn(Setlion 703I.5,Business and Professions CodeJ: -City Tel.No. ❑ I,as ownar of iha property,.will do the work and�he s�ructure is not in�endsd or offeted for aale(Section � � 7044,Business and Professions CodeJ. . CONSTRUCTION LENDMG AGFNCY � � I hareby affi�m Ihot thero is a construction lending ogency for tha pefiormance of Ihe wark for whith this permit is lasued . (Sac.3047,Civ.C.). 4nndee'r.Nmn., . — � � . le�rcle:s Add'sss— -- 1 certi4y�hot I have�ead�his applicotion and stote that�he � above info�motion is corred.I ogree to comply with all County ordinances ond S�ate laws regula�ing Plumbing,and h�reby �horize repreai ntarives of this Co�my to eMer upon the " ove-mPn�ion ro�rt�� in ti n pu s. � SEE REVERSE FOR EXPLANATORY LANGUAGB Signature of ermittee y Da�e �" � — - — ��-�. . � ' , � �, � � _ - , . . ' ., .' ,� �� •`y+�'`"�'� � �'_ Y�C?,. ��, - , -, ,� � _.� _._ _ . _ _ _ � _ ___ ____ ,,u i o- c-ac r�r �i� c n _�� �� n s re,�F r r ,.r �{.� p _ __ - -- - -- -- IIJ,..R _t4 l"l . 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