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HomeMy WebLinkAbout1313A � WO - 'COMPENSATION DECLARATION �q,pQLICATI4N FQR PLUMBfNG PERMIT � ,1 hereby,affirm thot 1 hove a cerlificate of consent�o self 76A667A insure,or a wrtifimte of Workers'Compensafion Insurance, CE 877(flEV.&/88) o.oce�tifib�to�f�S,pf.35�o�b c.-� ) g-- � CQUNTY OF LOS ANGELES �—.DEPT. OF PUBLIC WORK��� � P❑o�lcy No. C�pany....__ �'�_ii7 A� f_ Certified topy is here6y furnished. � FOR APPLICANT TO fILL IN(PRINT OR TYPE) BUILDING � Certified copy is filed wi�h the coun�y b�ilding inspec- ADDRE55 � . �f��(� fion depo�tment. NUMBER FI%TURE OR ITEM �, FEE � � �`� /tQ ��yy,t� lOG4lIN l� Dnte_S_i—LLLAppli�aM_ 5�`� 1'�7T� 'NATER CtOSET ' � NEAREST \ CERTIFICATE OF E%EMPTION FROM WORKERS' U BATH TUB Q'O CRO55 5T. I � . COMPENSATION INSURANCE SHOWER OWNER �� (This��cfinn nwd not M compFet�d iF fho work inrolr�d 6y fh�p�rmif b For ono hundnd dnifm�(SI00J or I�ss.) LAVATORV MAIL 1 � ADDRE55 I ceirify thaf in the performance of the work for which this permi�is issued,I shall no�emp�oy ony person in any manner SINK � CI7V ��y� TEL.NO. _ S' so as to 6ecome su6ject lo ihe Workers'Compensation Laws. �� � DISHWASHER E�CONTRAC7pR �SC�� Q L�n�e oppliconf CLOTHESWASHER O'Q �� � , . "ICE TO APPLICANT: If, ofter making ihis Certificate of ����55 . �mprion, you should 6ecoma subje0 fo the Workers' SWIMMINGPOpIRFCEPtOR - Compensation provizions af the Lahor Code,yau musf forlh- QTY �p El.NO �9 with tomply with soch provi5�ons or ihis permit sholl be �AWNSPRINKLERSVSTEM STATF /� UC. deemed re�oked. WATER HEATER UCENSE NO. �I�O L:J� CLA55 � � LICENSED CONTRACTORS DECLARATION �O DISTRICT NO. PROC€SSEO 8V I hareby affirm fhor I om licensed undar provisions of Chapfer 9 GAS SVSTEM Ol1TlET5 � 1 (commencing wi�h Sectian 7000)of Division 3 of the 8usiness OU7LETSOVER � • ,Y� and Professians Gode,and my license is in full force and effec�. 5 PER SVStEM FINAL �13b�3 � �/z./G`6 VAUDA710N � DATE J ticense Number_S Lic Closs � �+�,, I FINAL j�' /� BY ,*�`L�' . O Conlracfor 4S�-"��'� te ^`� '/'� p"' U ❑ � I om ezempt under Sec. B.BP.C.for ihis reasan � Plan check fee �-1 �7.�F� � � Date: p�UMBING PERMIT ISSUING FEf S '�S'� � r� ° ° ° •� Signpfure TOTAL FEE I '� q 7 6�J(� Plan check aPPlicam F " ��/r �i�� SINGIE PAMIIY � ' � HOME OWNER-BUILDER DECLARATION Nome ���„(j���j reby affirm that I am ezempt from the CoMroctor's License qddross � . Low for.ihe followinq repson(Seclion 7031.5,Busineas and Profassions Code): City. Tel.No. � ❑ I,as owner of the property,.will do the wak and�he i - structure is not IMended or offered for sale (Sxtion � 7044,Business and Professions Code). CONSiRVCTION LENDING AGENCY I herahy affirm ihaf ihme is a consiruction lending agency far 1he performance of fhe work for which this permit fs issuad , ISea 3097,Civ.C.). tand8ks=�FICYrre�-- � kemiedoRd6reaa- I cerfify fhot I hove read lhis oppliwiion pnd state ihof the � above informarion is correct I ogree to comply with all County ordinances and Staie laws regulating Clumbing,and hereby aothorize ropresen�aHvas of this Coumy to enter upon the obove-mentioned properry for Inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUA6E ��=��-�� g-'1�Q>`) - Sig�wluro of Permif�ee Dafe - 1 — � �a J �!AiA'�3'4 .�i�'1 li3A�l?J� �i`i �,��� �� ���i..r� r ._�� - - --- . � __ _.. ._.. . _.� , Rce{FA���,is --}T l}��� �;� � _ . `— i �c�-r s r�T€ �-�____— i��,.��_ r,f ,e ;5 �fi [c��, � � I-s ��,, �,�,.,r, - - �--._. --.._..-- ,, i s. �n ri.ra-. 4, , �i���'� � " _ _ a E rN i c�� � � , �y < rr �„�h _ _ �- •- _ _ _ .__ � ['ASbEI.t I -' _ , .. . _.- , . 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