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HomeMy WebLinkAbout1265A (6) _ .... �vMPENSATtONDECIARAiION APPLICA�TION FOR PLUMBING PERMIT � ii I h�eby,offirm�ihoi 1 have o ceriifiw�e of conaeN lo self ��b7A �� inswe,or o certifim�e of Workers"Compensation Insuraace, CE 817(pEY,8/BB) - . . .. .. o�a cen�Fied topy�he��of(�Spe,c,�.3e0o,tab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBUC WORKS ; Qcynw� �� Cdfipony +�U`S L�Ox/5"r Cer�ff�ed copy is heroby fu�niahed. ' �Q - F04 AiRtCANT TO flll M(VMIM pl iYPE) BUILDM6 Cer�ified<opy is filed wi�h the couny b�ildinq inspec- ADDREu � .. iion deportment. NUMBER FIJ[TURE OR ITFM p FEE ! oa�e?�/"e�'� AppiiSont LOCAl11v / �� 3� «. �'�'' ,,��+�. wwrtac�OSEi' SLlL�J'I �S . .. NEA4EST �� CR069 ST. �.�¢ �/ /�j� i . � G£RTIfICATE OF€XfMoflON fROM WORKfRS' BnTH TUB � COMPENSRTION iNSURANCE pyy�p ./7� .�. . . , (Thia r�dlon n��d�rof b�compl�Md b 1M vrorlc lnrelwd hY S+iOwEa � ffi�p�rmH b for om hundnd dollars(ff00)m baa.) iqvqi0av ��� ' j I ceri�fy thc�in the perfama�xe o1 the.wwk fw whtch ih�s AODREu _ . . permir is iuued,1 shall not emplq any penon in any monner �� CITY �/� 1Et,tdp. so os�o become suhjeu m the Worker5'Compenaotion Lows. : �. DISHWASMER ��raq�� /��l �. ,� S , Do�e Applicant - ' Cl07MES WASNER � NOTiCE TO APPIVGONT:If, oher makinp�his Certifimtn of ���y.+x . � QS� � EaempGon, yoo should becoms subjec� �o fhe Wo�kers' S�WMM�NGPOOLRKfP70R r� . Compensolion proviciorrs of ihe Lobor Code,you musf forih- �AWN SVRINKIER SYSTEM ��TY "��(�n�yf 1E�NO � ��� � ith comply wi�h such provisiom or Ihis permit sho71 be S7ATE uC, �j , � 'deemed revoked. � � Wq7ER HEATER ���E��� O � C4A55 !7 • � ' LYCENSE�CbNTRACTORS DECLARATtON � . DISTQICT rq. PROCESSEO 0v � � I hereby affirm Ihot t am licanaad urrder provisions oi Chapter 9 GAS SYSTE�N OUilETS � � (mmmencinp wirh Section�ODDJ ai Dinsion 3 oi Ihe Boaineu . OUAfi50VER . ' and Woieuiom Code,and my Gcerru ia�n full fwce ond effxt. 5 PeQ SrSTEM FINAL VALIDATION O license Numberj'���� lic Closs� . DATE �2� �� U �Qy FINAI� � '�. ConhaUo�•�5 �p$ pufe �"2 c+ i BY �_� � � � 1 am exemp!uMJer Sec. ,� B.BP.C.for thi�reoaon P{on check fea � . . ► �"1 2 b 5 A x , Dore: �:� • • • •5 , PIUMBlNG PERMIT ISSl1MG FEE f � . Signaturo � a �� �Jr O tOTAL fEE rp S . . . Plan cbeck appNconf • ` c 1 G 5(�'� SINGLE PAMiLY '� HOME OWNER-BUItpER DECIARATION Nome � � � � �G�'.�'i'� —8 7 � ' 1 Mr�by oHirm�boi I om exemQ�(rom fhe Conha[for i Lfc�nis �� Addraet � -� ' � ' � � low for.Ihe followinp rewon�Sacfion�03I.3,Bwineu and � � Professions Coda): City Tel.No. � ❑ I,os owner of fhe preperty,.will do ths work ond�he ► st.uclure ia nol Iroended or offered for wle(Sec�ion � � � � � _ 7044,Businev ond Rofes�ions Code). . CONSiRUCT10N GEN�ING AGfNCY � � � - � - - I hereby affirm 1ha��here is a coa�truction lending oqency for � Ihe periermonce of 16e work for which�his permil is inued � (Sec.3697.Civ.C.j. lende�'s Nome lender's Add.ess . . . . I certify thol 1 hove reod thi�opplicolion o�d sble Ihpl�hs � � , ► - � a6o�e informoHon ia co�rxt.I aqrae ro comply wi�ir oll Couny � ordiaances ond Store lawa roqulafing Plumb�np,and hxeby .. , . . . . au�hwize ropreae��Wivea of this Cooniy ro enrar upon the �cbo.e- ntioned p.ope�y fw iaap«tion purpwea. SEf REVERSE fOR E7CPLANATORY MNGUAGE - � � �¢���-�--�'-z8� SignoNre of Pe�m e� Dob - . . ..., , �, . . , `a:._ 'I , � .._. ,..� .. - ", t ... ... � , . .. , •' .. � ;. � . . , .. . . . .. .. . ... _ ._ . . .. . �. . e ... .. � _. .t � .. .. � ,i -. �„ . � � ... . lNSPECTO h,OTES .. .. �" . -j �. f L �G R l Lt .. �l . . aFaG�\q�5 DATE I.l c�70 55 �ANRE ) � . ._ . .__�.- _ ... 'UN.7ER5'ACVJDRk '. .. . . • . . �.'�' . ."�.� ..._. ~� ��[S�\h \ � \ �u Y . I '1 � �C 4 t � C-�i� . ci^ (_ ROUGH Fll'1.'E..�..... ... .. „'--".�.........__ .,. _.�. ._.._ �.'_._.. . _.r.._. .... .., - -___. �l'c��rs L,.�r� f�� t ..(,�II_+.in� ...��i.;5 tf,on lOJ7 5. G�5 CI:VG�.':.�.a (..', .�.=��. .�—\��C' �. ... ..,�, ".�,�. ,';,'�� ` Pi�si c 1 P ol (.c 1 a Y ��Y o� r� I'ch :-G Sl;t�T. . ... — � \l.l.._ .y -_. �.- I ___ _ _ . _ yv 'p.' � � L r I . j I sh. . .-. fl r �. 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