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HomeMy WebLinkAbout1309A — — —_ - - � �.�- .+ ----f— —-_ --- �- WORKER3'COMPENSATIONDECLARATION q�pI.ICATION FOR PWMBfNG PERMIT � ,1 hereby,affirm thal I hove a certificote of consenr fo salf �gq867A insure,or a cerfificole of Workeri Campensation Insuronce, CE 817(REV.8/86) � , � or a cenified to,�� .3� ,Lob.c.) �� YYS� ���.. COUNTY OF �OS ANGELES DERT. OF PUBUC WORK3 P�ol'icy No Cmpany�-CYt�LL. r Cerlified copy 15 hereby furnished. � � FOR APPUCANT TO FIIL IN(PRINi OR TVPE) BUIIDING � �/ n �` �Cenifiad topy is filed with fhe county building inspec- ADDRE55 W 1�- � tion departmenl. NUMBER FIXTURE OR ITEM @a' FEE ��A��T� � � �e a WATERCLOSE7 � � '"`��r�� �' Dafe�APPIiSam NEAREST � BATH TUB CR�u ST' � ''M'flR CERTIFICATE OF EXEMPTION FRDM WORKERS � ' (jI.7 COMPENSATION INSURANCE OWNER (This s�ction ne�d not b�completed if Ih�work Involv�d by SHOWER �fl tho p�rm8 Is for onr hu�rod dollnrs(f100)or I�as.) LAVA70RY � � �IL ADDRE55 I certify thot in the performonce of the work for which Ihis permil is issuad,I shall nol employ ony person in any manne� SINK QTY C� �; 7EL.NO. _ � so os lo bemme subjec�lo fhe Workers'Compensa�ion laws. DISHWASHER �'� CONTRACTOR �� P' �. pa�e Applicant CLOTHESWASHER a� qODRESS � �� -O� S "�CE TO APPLICANT: If, afier making this Certificote of SWIMMING POOL RECEPTOk � _�mption, you should become subjoc� fo the Workers' Compensalion provisions of 1he Lobor Code,you must fonh- �qWN SPRINKLER SYSTEM CITY � e � TEL.NO � with comply w'th such provisions or Ihis permit sholl be STATE y� LIC. rY r� deemed revoked. WAiER HEATER .� LICENSE NO. ��.0 CLASS � V LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm fhat I om licensed under provisions of Chapta�9 GA5 SvSiEM OI1itET5 �'p I /�'� Yi�n,,QA D n� (commencing wi�h ScUion�000)of Division 3 0(�he Business OU7Lei50vER ` "' ' " � � and Professions Cade,and my license is in full force and effect. S 7ER SYSTEM FINAI VAUDATION C: LicenseNumber �130�3 �,�.��a55 ��� DATE �/�-� �� v (� � fINAL ^„ n�., 0 Con�ractor ��l1PQ. "C"�(�B' 8Y �/� � � I am exempt under Sec. � 0.8P.C.far ihis reason � Plan check fee � � Daie: '�1 ��Q 4 A PLUMBING PERMIT ISSUING FEE E Signature � � t,I m o � o •j TOTAL FEE - Plan check app�icont � � ����5� . ' SINGLE fAMILY ... .. �,: c;-�,-`T � " � HOME OWNER-BUILDER DECLARATION Name � � � � .tsby affirm thol I am axempt from the Conhactor's License pddross �"•U c'`�'a 7 _ taw for the following reason (Sec�ion 7031.5,Business ond Profe�sions CodeJ: City Tel.No. - ❑ I,as owner of ihe properry,will do the work ood rha strutture is not intended or offerod for sale (Se�tion ► 7044,Busineu and Profassions[ode). CONSTRUC710N LENDtNG AGEWCY 1 heroby affirm that there is a construcrion landirg ogency for fhe performonce of the wwk for which this parmit is issued (Sec.3t147,Civ.C.J. kr�n7aKs•Rome�- . ketdeds�.4ckfreer I certify thal I hove read�his applicption and sfote that the � above information is correcl.I agrae to comply with all Counry ordinances and Sia�e laws regula�ing Plumbing,ond heroby aufhorize rapresentotWas of ihis County to enlx upon tha above-meniioned properry for inapettion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � .;�yL:��`� [��- natur� ��� e af�ermitte4� ` Dafa � � _ _ �i . � , . , . - . .'3._ a�__ � .�..: �� � t �" � . � ''��� �� ..,. . . . e.. _.�. ----- — -- -- __ _� � �rtti-orr r�rr _ � c'eRR�►SC+w�� �.,r�+r,� :� PF' .']✓A S TF Ir 5�i 'L ..._ . ._'__�.�. _�—�_ . __ _ ._""' '_ Uf.CE�' fAR O',c _�' � J � � . . . � .. r ., - , --.` . ._ . -, -., �i Il : I or �-�I f� I Cc, _tc.r.. RCJG�{r �..; '+ I. ' ._ . __ . '__— —"_ ._—_."_ '—' ' . 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