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HomeMy WebLinkAbout0772A � WORKER3'COMFENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � I'�hereby,effirm Ihat I Mve a certifico�e of consent to seif �eq887A � . . insuro,or a cmtifimre af Wohers'Compenwlion Insuronce, CE 817(qEV.8/88) � - - � � or a S r �d co the�aof(Sec.3800,Lab.C.) . � . - ��Opp/��7p R�ica�7�f,��/, f-,�"�5', COUNTY OF LOS ANGELES DEPT. OF_PUBUC WORKS ' Policy o. Compony . . � � - �. Certified copy ia beroby furniahed. � � - � � FOR APMICANT TO FILL IN(PRINT OQ TYPF) �p�� (`�2_ 2 �/ . Ce��ified Copy�s fifed with oty bui i � Ps�- NUMBER HXTURE OR ITEM � FfE tionde e�L � �p�,�,��iy fi/A,�� �ole ��� �qcDo�(.o �w' 2 WATEA CLOSET 0 N&1REST V•'T �1 . . � . CERi1fICATE OF f�EA�PTI K BnTM TU8� �A06S S/. (p /{� .. COMPENSAiION INSIIRANCE SHOWER ��R V �. �eS . (Thi�s�alon m�d no►b�cvmpl�t�d N f6�work Inro�wd by tA�q�rmM Is lor enr h�ndr�d dollan(iIOD)or I��r.) 2 LAVAiORY 2 0 b �owr�ss � � /� � 1 cerGfy�hot in�he perfvrmance of the work fo�which fhis pe�mil is iss�ed,1 sho�l not amploy arty peraon in any manner SINK CnYNPwP TEL'Np/�„ $Sr so as ro become subjea io the Wwkers'Canpensotion Lows. � �� � DISHWASHER cor�rancroa NO /t/G� Dolg Appli�pnl � CIOTHESWASHfR ' � A��� /� ��� J� O� �� NO110E 70 AVPLICANT: If, ofror mokinp this Certificats of (O ' E.emplion, you should become subjact lo ihe Workers' SWIMMINGPOOLRECEPTOR Compensalion pro�isiom o!the Lo6o�Code,you must forfh- �AWN SPRINKLER SYSTEM CITY���/� TEL NO. �Z�O wilh comply wilh such provisiorrs or fhis pe�mit aholl be i��� �7�g/_ LK. 2_ deemed reroked�. � r WATER HfATER �� �5 �� LICENSED CONTRACTORS DECtARAT�ON D�SiRKT NO. D 6Y SR I hereby offirm tFql I om licemed vl+der provisiona of Chapler 9 GAS SYSIEM OUTGE75 � (cammeMinp wi�h Seclion 7W0)of Divnion 3 of the Business . OUTIE75OVE4 ond Professbm Code,ord my literna is in full force and eHect. 5 vER svSTE�n FINAL VALIDATION O �7�C�'pP - DAiE U Licenx Number �� lic.Class� HNAI ¢ Contractor��Fl� ��£' Dare �—��v7 BY �,�/`� U ❑ I am exempl u�der Sec. � 8.8P.C.for�his reoaon � Plon check fee , Z Date: PLUMBING PERMIT ISSUING FEE f 'G 7 7'��` Signpruro � e e .r ' TOTAI FEE b $' � Plon check opplicom S.A�K� at-S CFyTa�scqa I ` `���� SINGIE FAMILY � NOME OWNER-BUILDER DECLARATION Name • • °�! �,�D� 1 heroby offirm that I am saemp�irom ths Conrwctor's lic�nu . . . . . . - . Low for��he fo4lowinq r�aaon(5sctlon 70Ci1.5, Bwinea ond Addre�s - Q'),�L'—%�7 Wofes��ons Code): Ciry Tel.No. � ❑ I,as owne�of the property,.will da�he work and the slruclure is nof inbnded or oHerod fp wle(Section ► 7044,Busi�ss and Vrofes+ions Codej. CONSTRUCTION LENDMG AGENCY - � � � � - I hereby offirm tho�Mere is a conahuctlon lendinp ogency for . . � �he periormonce of�he work fo�which ihis psrmit i�lu�ed � � " (Sec.3D97.Civ.G.). - Lender's Nome N/� . � � LendePs Addrsas . I ce�t�fy thof I hove reod rhis opplimtion ond sra�e tMt the - � � � � � � - o6ove inforrtwrion ia conxt.I apree ro canpiy wirh all County ordinoncas ond S�o�e lows requfotinq Plumbinq.and hereby . . . . � authorize raprese��Mires of Ihis County ta anler upon fMs above.menli ned proper�y fw Impaction purposes. SEE REVERSE FOR EXPIANATORY tANGUAGE /f- I 7-Zf �� Sip t re of e ittee Oote � - . I• �• - n S' r . � .. - .I. ��. '. .. - , . : . �... � , . • . .. . _.. . .. . � r . . . �. �. . .. . . �..:.,._ ,. �.. . . ._:�...:.'...'.. ,. . : . .. ..,� ..� .! i. � ' ', " ' ' ��...^, �: �.. .. . .;'; . .,. ' :,.. .. �...-, :�.. �'� AFF60vAL5 INSFECTp2'S NOTES � ,,; . '.�.�'.'�.- . . ... �. .�-'' C) � ' f3WlL i k l�C�l�KF,'C}^�� � ., DATE I.SFcCTOF'S9GNaTUaE - .. . 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