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HomeMy WebLinkAbout1237A ��, WORKERS'COMGENSATIONDKLARATION APPLICATION FOR PWMBING PERMIT ' I here6y offirm Ihat I have a cerlifico�e of coosenl to self 20�00]8 DPW 8/87 � �� insure,+6r a cerlificaie of Workers'Campemofion Insurance, 76A687A :b.-8 ca.rfied py rlro�ep�(�jX�ea 3eo0,lab.C.) COUNTY QF LOS ANGELES OEPT.OF PUBLIC WORKS �� Q�Y��LoMpony . � . . Cenified mpy is heroby Pumithed. FOR AVPLIUM TO Flll IN(PRINT OR TYPE� BUILDING � � Certified copy is filed wirh tha coun�y build� Irnper �DORESS �1 -� �ion deporfinen. NU ER FIXTURF OII ITEM � F� lp�jµlTY � pol ppliGan WATER CLOSET �qpEST ' �, �I� CE CATE Of EXEMPit N f RKERS' BnTH TUB Cko65 ST. COMPENSATION INSU CE ��� OWNER � � . , (1'hla�Mlan n��d nof b�completed B th�work Inwir�d 6y �� y ` fh�p�rmU is for en�hundr�d dellars(f100�ar I�ss.J wvniatY qppq� .S � I cerfrfy 1iw1 In Ihe performonro of tbe work fw which Ihis , pe�mi�is issued,I sholi no�employ ony penen in ony monne� S�NK CITY 1EL.NO. ao os ro become su6jx�b rhe Workma'Compenaotion lows. p��WAy�R �pNTRACiO ~ - Dofe epplicont CL07HE5 WASHER �. NOTICE TO AGPLICANT: If, after makieiq lhis Cenificab of ��S'`'�� � �, Examption, you �hould bxome subje9� fo Ihe Workers' SW�MM�NGPOOLRKEMOR Compenaoiion provisions of�ha labor Code,you mus�forth- IAWN SORiNKtfR SYSiEM � Cttt ��� � � � ith comply wl�h such provia�oos or tbia permit shall be STATE LK. deemed revoked. � WATER HEATER LI�NSf N0.3 CLq55 ' LICENSED CONTRACTORS DFCLARATION DtSTRIC7 NO.` PR�BY � I heroby offi�m tMt I om licen�ed vnder provisfons of Chaprer 9 GAS SVSTFM OUiLETs 0 �Q � (commencirq wNh Sec�ion 7000)of Diriaion 3 01 fhe Businaaf pUTlE7S OYER and Frofmlons Code,and my license is in full force nd elixt 5 PER SVSTFM FINAt VALIDA710N �" License Number;�lfc.CI �' .,'� �� DATE � fINAL Conlrodo��lq� BY d' ❑ I om exempl der c U . B.BP.C.for rhis reason plan check fae ► � . � N Da�e: � Z PLUMBING PERMIT ISSUING fEE f Signolu�e TOTAIFEE Plon check appliconi SINGLE FAMIIY HOME OVJNER-BUIIDER DECLARATION Nome I heroby offirm tha�i om e.empt from the Com.ac�w s License �d� tow{or the fotlowiny reason(Sxtion 7031.5, Business and Profeseion�Cede): Ci�y Tel.No. s� c J,7 Fl ❑ I,oa owner of the properfy,wiil do Me work and ths � � #• � • • •5 ofrucfuro is noi inronded or offe.ed fo�sale(Ssction , 7044,Bminesa ond Rofefaions Code). � I • ^G 2,�� CONSTRUCTION LENDING AGENCY �hereby nffirm thct�here is o wnstruction lendiaq oyenty lor � - • •a L 2�O`u Ihs performonce of tha work for which thia permit is iuusd (se�.sov�.c��.c.l. �$2 9—8 8 Lende�'�Nome lender'�Add.esa � I cenify�hot I have rood ihis applicarion ond t�o�e Ihof the . � obove informo�ion is rorrcd.I pg�ee to comply with a�l CouNy o�dinanca�ond Sro�e lows ropule�ing PIum6�ng,and hereby outhorize ropre3enMlives oi rhis ounry 10 erosr upon�6e . a6ove�menlioned��rtyforin eee���yyy���nnn purpo�es. � ,"� �g�{� SEE REVERSE fOR EXPLANATORY LANGUAGE .� ignotur f Per i� Dme � . �` . qr�aOv:,:s �A1c�� ir.S�ECTOa'SSiG'.ATURE �� � � IP7SPEC.TO.�^,'SN�i[S � � , . O�,V�JE2-BU!LDER'�"cCl_A.%2P.TiGN � U.^1D`��lna W0�2K _ - . . l hernby aEfvm thd!I�m c. mpt irom fne Co�'.,ci^,•: P�UCH CLU".tC':'i � . "'-- � . - . -�— lic�nsc L�v: for Itic iollo•r.•'��� rca;�n (Scr�inn �03I.5 Gqc^n,��,�-, ' . '--_t. . - - 6 5 ss and Prolessio .Codsi�.Any cify or cc� �y t�:h GFS VE�T --�— . �roq . o p�rm�l to ro s r.aile imp ovc,d . -I�a.h repai. o�y s�ru'cr re,pr o��o U .i o n:c afso ro- N'�;1ti�PTE2 N�ATEv . . . .. - . Gui�es 1hc arp!ico.�l�f�r surh�permit to 1�ic o si�r,^js!�!e� P:U:'•9:tiG fi%Tl;FES � � - � ' men!Inat 1i-ts l�cer,sedpursucnt fo t!��x provisicns o?!hc� GAS�ESt Z - Ccnfroc'or"s'Ucens'e Levi(C6opf�r 9(cammbnc�.�g�•-�tl: UT'LITY-CO.KO?i�leb �- � � _ 5^N�on 7C00;ol Divisioo?oi 1he 6usiness and Pro+=s- . , s�o�s Code)or thcl hc Is nvemr�thern'rom bnd�ne Sos�s � � c�7 � - for ffie alleqed c mptlon. Any violaflon ei Srcrion F;�;�� , � � �C"n(rr nn�_frnnl ' - � �� 7071.5 6y ony cppilcont ior o permi!subJe,ts Ihc oppli� eonr ro o e��;r p�n�rry�r n�rmo�r rhv�r��ru�d�ed -- - . doI(crs(55001.: L^JD'JS'FIFI • . , � . . ❑1,es owner e`�he nrepar;y wi',I do f:ic x�o-I::nn., ��'%+`T`-A��^'�'�F=� � � � � �he svucture is nor Inrended er off_red fcr sale. � - ... � ' . (Sec.70A4,6uslnessandFrolessionsCode. >heCor.kec- , � � , -- - • � � � �or's Utense Lowc�oes rte!eppfy ro on own�r oF property � - � -- . �� - - v�fio b✓i(ds or Impraves f!:emon, end w-ha does�such • � � � � � ' �' � � __ '— work h7mseff provided ifiet svch improvements ore nof �� � � , . � ' � 7n�endedorol(eredforsafe.,lf,howevcr,thebuildingor - � � � . - � - � • lmprovemenl Is sold wi�hin one yecr o(ca^.pferion,1he . . . .ormer-buiider v,7ll have�hc borden ol proving h`o�he c�d . � � . � . �not buffd or Improvc fcr ihe{+urpos�of sa'�.1 � � . _ _ � t c.m excmp`undec Sec. ' , . , . � . . . .. ���,, . . � � "- �- 6 F.RC. ior;his reason � ' _ . . Dmc____�,_ __._-- Owner INSPECTOR'S NOTES • - -. _ • -. ... . _