Loading...
HomeMy WebLinkAbout1312A � WORKERS'COMPENSATION�ECIARATION APPLICATIAN� �OR PLUMBING PERMIT � ,I hera6y,affirm fhot I have a cerrificate of mnsent ro self 7gA887A insure,or o cerfifimte of Workers'Compensation Insurance, CE 817(REV.8/86) or o ce�tif�ad copy thereaf Sx.38W,lob.C.) f� �}pQ; COUNTY dF LOS ANGELES .--, DEPT. 0� PUB^U�C WORKS P�ol'��Y No��1 I[ �o pa�y . �s l L� � Cenified copy is hereby fumished. � � FOR APP�ICANT TO Flll M(PRINT OR TVPE) BUILDING Cenifiad topy is filad wilh the counfy 6uilding inspec- ADDRESS Ph, � }�on deporim-a^n1f. NUMBER FIMURE OR ITEM � FEE �OCALITY �� m_�� � Dale `_L�LLAppIiSaN ��C �� WATERCLOSET It'� � NEAREST � , CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ' CROSS SL 1, R-�L.� COMPENSATION INSURANCE OWNER \ (This��cfion nud not b�wmpl�fad if th�work involv�d by SHOwev �Q.�E'Yl tM parmif if Por oM buedr�d dollnn(�IOD)or I�asJ iqva70Rv 1 ^ � Mnil �Ol ADORE55 I ce�tify�hat in the performance of tha work fa which this permit is issuad,1 sholi no�employ any person in any man�er 51NK �y� CITY `�`,.� 7E1.NO. ��� s 50 os to become subject lo the Workers Campensotion Laws. pISHWASHER I � CONiRACTOlt � �� � ppte � 6pplitaM CLOTHfS WASHER � qDDRF55 7� � TICE TO APPLICANT: If, after moking this Certifimte of SWIMMING POOL R€GEaTOR D v ��� emp7ion, you should become s�6jact ta Ihe Vr'orkers' Compensaiion provisions of the La6or Code,you must forrh- LAWN SPRINKLER SYSFEM ��rv TEL.NO. ,. Qg wifh comply wilh such provisions or �his permit zha�l be STATE LIC. �{ deemed revoked. WATER HEATER UCENSE NO. I CIASS l.�_.� UCENSED CONiRACTORS DECLARATION UiStRKi NO. PaOCE55E0 Bv I here6y affirm ihat I am licensad under pravisions of Chapfer 9 GAS SYSTEM OUTLEIS �(� I ^� ry-�Q 1 p � (commencing wirh Sectian 7000}af Division 3 of the Business DU7lET50VER <<� � � � gs', and Professions Code,and my license is in full force and effecf. 5 PER SvSiEM ����-.�� /1 DA EL ���y/� VAt,IDATION � Litense Number c1\ v4�1 Lic Class v� � FINAL �„n� d � Contractor 1� ��ate� BY if6 � ❑ I am exempt under Sec. C G3 B.&P.C.for m�5�eo5o� Plan check fee � .=1 3 L 2 A = Date: p�UMBING PERMIT ISSUING FEE E 5 t`u � a� c a� Signature TOTAI FEE � °'�'"7 E��O Plan check applicant L �. �,%�.5(1 T SINGLE FAMILY � = HOME OWNER-BUILDER DECLARATION Name ('�',(J�,�-F% .reby affirm rhat I am axempt from the Contractor's License qddress . law for Jhe follawing reason(Section 7037.5,Businass ond Professions Code): Ci�y Tel.No. ❑ I,ae owner of fhe property,.will do the work ond�he strutlure is nol intanded or offarad far sale (Section ► 704d,B�siness ond Professions Code). CONSTRUCTION LENDING AGENCV , I hereby affirm ihat ihere is a constrodion lending pgenty for ihe performance of the work fo�whith fhis permit is issued ISec.30�47.Cia.C.). kerRiaYs F1aRlt � temler'r Adtl�teta - I certify that 1 have read�his opplication and state thot ihe ► above informa�ion is mrrect.1 agree to comply wilh all County '� ordinonces ond Stata laws ragolating Plumbing,and heraby au�horize repreeentotives of Ihis Caunfy �o enter upon Ihe � above-mentioned propeny fo�inspecr�on purpwes. SEE REVERSE FOR EXPLANATORY UINGUAGE � ' r ,� �1�� _ Signature of Parmi tee Oate .i . 1♦ ��3��="" - ��� � � � � �$. '�� � �'.ii'. _� � , , � �!�s� '+r�rT��i ..,_�- _ _ ' ._...._ �.,_-. _ _-__ _. ---- -- - � - _ , .__.� — 1 �a,,..�,s�-_ �" 1 J�fe iY)R'S fvClFES i•r�ii I ��R C c"1 W Ti'T' AF"r"5 F S Uy1: I 1� , 1,Tll' ""_ _._._ __._ _ ___ ._"'_—_.__.' Uf[f.G f L Y f �I (�// � +��� � . . . ` _ ___L�( . i/ �.� . •� � R 1('N.F.II.`, 1 . ��{ ,�� I , � .�' __ '_�._"__._ '.:_.- .'_'_. ..'. —'_--__- � � . �c1 f, il I ���i cf` , Y.,�I;. . . _ .__'"'�.a -- t ,,,yyy_��� �����- . . . , � .r .. �' GASC .G �� «�! '�.. . . .._$ . .. _ A y ;�yo ti .._ ..._" _ '_._ ' _'�. �_. � . :"'_'_'__—_ . � . . � G 5 V.}uT I : I ' � �. .. . ... . . ,'r f}F �p � r, �. �'-.I !..h ._ _..... :_._.,_ .......... . ....__ .� �. ..... .._ . . . .. . ru- c �s;u f-., P . . o re 3 � FIOT VJR'CQ F�ATE� . . I - " .,-. .�,_1.._. .__.____-- .-_._-._�__-.__�.—_. -.--_„ �ui;ee 1 cer;�l:tc t f i F` i .��!� s �d far., � _ ._._ ___ f __ ' a��E►.Af��Kt� , I � ,� , . . . . . . . , .�nrr7 ri .1�- ���. ir rh.. p or�no — - --� -"� ' '.' .�•--. ..--�-� ----- - --- --�.� ' � ' C nir�c c s c vs Lc i 9(ron � c-rrn wi!h l , Ch G�5 TE6i ,___ ____ ._ ..- �_ i.... . . .. � 5� fic��i 7 J9)o!D s o 3 ai t 9� n.�s d Pro�es- �7RlTY41'.tda G.e�f . . __. . __.._'�_ .-_ _____- ._"_ _..-__ ._._ . —' __ _- _ ___ __' __ ^ .� � . .. . .. .. . s,..�is C,.d�)�, ,hu ,5 R rr,er'?,11h. C,T�'n an�#Lhe tlosis - � �� � �or nh A.;; . •�pr„n F y ��.,tc,r�on o! s<�cnon ,., ._.. ' . �_�_.. ._.._.____. �_____ .__...,,. _._..______.. .__.'_' R��at - �. C'.i F- nn c�on1 � . � 7�7lS t, c;:; � f..�a F�� .�I ud� �t.��r� d"rP�'- �- _._- .—_- .�'._ _,_ s ' . _ .. ... . ._ . � �P i e a d p i y f n, n o 7h� u hundred __ ._..._..... __ __-__- _ _._._ --�..__-_'- . .��i. .�_ . . ._ .- . . cl'c•.,( �� ._i_. _ .. . _ c f DU �+ . . -. � -� . . . . . � - ��I c i ri t �II F �rk.and __ __----- - —.._ .....__._.. _---_ _.------_ rr s,� r �� r r T ,r ! L ,F.::� t ' , . .._i _ ,� � �__.._ _{e.�.�. ..�.__.4w.. _ ..�,_.: . �........... ..� . .. . . . ' �. '�a cr J 'c.�.s.��:,Ccr..� I e Cc " . .. � . . , ..-.� -. .'_ '____.___ . _._._. _.- ___.__._.__.—_—.._._ , , �,'... �` �, .:� � . ,. . .. . . tc�s L I �� r� r-. 7.���f _ �.ov, F-aperty .. ... _ ., . . . : . � . w.�ic.L�...�. nr�i❑ : foe cr: �5 „ d.�ca such � � . ' . _ . . � ..._ , n:�1. _r fr�,rc .1 fLni�-'.+ � _ . . ar not ; . '�. . . . �o .?r��v �. s c . .. �. . , . .. .. . �'. Wc:n.i��v cJi.-r� (,=.r s:-l9.��-.e .serr�.th-tuildrn.q or -� � _._.,-_ �._._ . _._.... .__.___ _._____. __._._._'.___'__. � ,- . � � � _ � ii.p:� ��fis�a .,.�r,ar l--relc�n .�� �on tne ._ ;, � . � � . ! . .. . _ .. . o4F:�r �.,wi�,l. . }r,ab� n.an{pro g�._�haoid .. . . . . . . ._ .. . .. . ..__ _.._:.____ .__.___ _..... _._ .. .._._ . _ . . . . . .. __.___ ._ nM t�Net c.trnF..rc.w/ur the y�rn�a c!s±ie.! _.._ ____ _.._-_.-_ ._..... _._.. _._ _ _ � ' � . . . . . .. . . . .. . ... . i a,.il ..,F7'L'il '�::._..__ .__..._:.:..._.__., . . _ . r . ...f-' . . . .. . ' E3 L.f:C tor�iii�5 re:n'�on__ _ . .. .. _ _ .. ._ . _..__. _._____ ._._....._. _ .._._.._ _________— '� _.____.__-____...__'___ j.. .._ ..______-__________ - .. . . . . _. . . . . = .,: . _. � . . .. , I . U<�n.-_ .. �— _-_._._------�— -- O�ani:r-- __.�. -_._____�_ __ . ._.___ . ,___'_..____. ... . . InSF'ECTO�'S h0T?S . . ---- ----- -- _.____ ------------------ - � ----------------------- -- --- ---__-- �--------