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HomeMy WebLinkAbout1296A � WORKERS'COMPENSATIONDECLARATION � ' �' APP��CATION FORPLUMP�NV PGRIYIII . � . : � t hereby af{irm that I have a certificote of consenl fo self . 7ypby7q- ' � - . insure,or a certifimte of Warkers'Campenwtion Insvrance, � CE 817(REV.10/81) �� - � '. � -� .� : _� . �p � � ar a certified copy thereof jSeC.3800,tab.C.) '-�, . � � COUNTY Of.ROS ANGELES `,BUILDING AND 5AFETY � � � � - �. POolity No.., .. Company �. .. _..� _.': , �� ..� ,� .� . .. .. �. � .. . : _ Certifled copy is hereby fornishad. � BUaQiNG � - " ��' ' - �. fOR APPLICANT TO FRL IN iPR�NT OR TVPE) ��- ADDRESS � +� IP'1�� ��I�^ � :� �Cerlitied cepy is filed wiih the coonty building Inspeo- � �NUM9ER .���FIXTUREON IiEM " c� FEE :� � - . � �� . .� tiofl dBpOr�mNn�.�... ..� .. ._. IOCAIITY. ��'�./"r.:. ... � ''. .Oate � . �� AppLtant � . WAiERCLOSET .. � .�-'� .� - � N6ARESt� . . . ,�} . . " ' : � � ��CERTIFICATE OF EXEMP710N FROM WORKERS' - BALN iU0 � . � CROSS ST � � KJIZAfA-� ��I�'iM1' �'1 ' '-� ��CA/c�PENSAT40N INSURANCE -��' � - . OWNER�� .d �,� .' r"�"'� �. �q� ,$ . � ' � " -- � . SHOVJER� ' � .(Thi��eetioa need not be completed if fhe work'Involved loy��� � �- Mqi� . . � ��1he permif Ir for ona Aundred�dollan�(SIOpJ or bss.) �� . � LqvaTORv � aOORESS � � Y'y1�� � � !certify Ihat in 1he perfprmnnce.of-!he wark for which thii.,.�.. �-SINK �� � � �� � � �� ,permit is'ias�ed;'J shall not qmploy any Qerson in any manner- �-�� ..�� �� CtTY� ', -, , ���' tEl.NO.�� '' --�� . .so a:�o tiewme subjeer to.the Workers Compensation I,aws.�. _. -DISHWASHER �� � . CONiRACtOR "�date °pplimnt ' �� � ' ClO7HESWASHER . �"� � � � '�- �.::. AbDRE55.� ._ . . . � � � '� �,. � - NOTiCE TO APPLICANTi�If, after making�ihis Certificate pf�. � SWIMMINGPOOLRECfPTOR-� - � - . � �� Ezemp�ion,�you should�became�su6�ect�1a .�he-Workers' . CtiY � '� � � � � `Compensation provisions af Ybe�abor COde.,yoV musf{orth-. '.iAWNSPRINKLERSYSTEM � � -� . �� - . . -. with comply with such.provisions�9r this permit shall be-� � � -STATE� � UC. . . ` � �. deemed revoked. :: . ' . �� -. � .. :WATER HEATER . . ... �,��I.�CENSE ND. CLASS - � �-�. IICENSED CONTRACTORS�ECLARATION - � / � �ISTRICi N0. . ��PR ESSEO BY .�. , � � - GAS SYSTEM OUT4ET5 �� ' �I hareby ot4lrm that 1 am licensed u�der provisions of CFapter 9 � �(- � � ' . .�. ' � (commencing with Seclion�000)�of Divlsion�3 of the Businesa�� OU7LETS OVER � � � �d 1 'ond Professpn3 Code,aod-my iicen:e is in fvil force and effecr.. 5 aER SvsT�nn "' pINAL � �/ � - V,�ILIDATION ���� '� .. .. � � � . .. DATE �� "�,,�—R,'- y -...�� ��.i . t,i li �Licanse Number �lic.Clats � ; � ' . . � - FINAL.. .. � , . OF- I Contrac+or � ' Date � ... . 8Y - �.�� �'`j ,i .. �'❑ i am examphunder Sec. .'� . . � . .. � . .. , �. �.1 2q,6A; N ' - B.BP.C:for tMs teason . , . . : ...� � . . #:�'�'r�• •S; � Plan check fee � . .Date: ; . .. . . ���� � � . �'a �2�2-J�IJ. � . � . . PLUMBING PERMtT ISSUING fEE$ - . , � � - �, Signatvre . ' .'4•"•2��0"cz.> I . � �� �TOTA4FEE � - � .. . .��' . . . : :� .� � � , � ' ...i . ... �.. ���� -�� . Plan-check aPPlicant �� � . �� . �Q�$,��-8�J� , � � SINGLB FAMIIV � . .. :�. � - � HOME OWNER-BUIlO£R DECLAIZATIDN Nama �:p' ,�� ���i•T/' � ,/�► . �� � ��-" � � ��-- �I hereby afti�m that I�am�eaemp�from the Contractor's license� � qddress� � /frPV.� �- - � � - � � � �Law for.ihe fallowing reason(Settion 7031.5,Businass and�� �� �� , � �� �Professions Code); ��-, :� -.. �. � - City�� ��y N Tel.N . ,.75'Z, � - � � ._� I,as�owner of rhe property,will da the work and ihe� � ' � - . � � . . strvcture is not intended or offered for sale (Sectlon , . ..�:,r . .. -. . . 7044,Businass and�Profesabos Code). . . .� � � � , � � � CONSTRUCTIQN IENAING AGENCY � .. . � . � .. ,. . . . . ., . t hereby affirm that fherels e�constwetion Iendi�g ag0ncy for, - ' - � � �� � � � - � . � . '� -� �the performance of the woik for.which.thts pe�mit is:issued- � . �.' ��- . � - . . .. � � .�(Sec.3097�Civ.C:).. . �.. . � , . . ,�. . . . - �� � � , . ��, .. .lender'sName . ����'��'�' .�. .. .... .� � . . � � . .LendePs.Addres3 �.� , . . .. .'. .��. � - .. .. . , .. .. .. ' . . �. � �1�cerrify rhai I have read thrs applicar�on and siate that�he , � .� � �,� � - � �'. � above infwma�ion is correcf.I ogree to comply wiih ol�County� . . �� � ' � ^ �ordinances and State�lows.�egvloting�Plumbing,and here6y . � � � �-�. - -� � -- . . � - + . � �. aufhorize represeMptives af ihis Counly to enler upon the • � �� ����"' . , '� � � � � � . � g �� � above-me �oned properry fqr insp ciion purposes. .SEE REVERSE FOR EXP4ANATQRY IANGUAGE � � . . � � . � r9,� : ',� Si atore of P ee � . - �Date . - �.�... .�� ��.. . ��-�.. � . . . " � . ! �. _ _ ... _ __ _ . __ - - _ . . � nreaovn�s onh ira5aEc7oR'35�crwiuke �NSPECTOR'SNOTES OWNER-BUILDERDECLARATION ' UNDERSlA6WORK � � . � � � � � I-hereby affirm that I�am exempi from'the Contractor's �, i� ROUGry PLUMBING � ��� � -� �� '-� �� � � � � , � �� �� , � � Llcenae,Low for tha-following reason (SeNlon 7031.5, . GPa PfPING '• - '.., .-�.�. '. . . . �. . . -BuSlne{i and Pro/essfons CodeJ:Any tlty or county.,whith GAS VENT � � � '•� � � � . � ' � : . .�: . . requfrcs�a permlt to construci,a7ter,Improve,demohsh, � _ - � � � � or repa(r.ony sfru[fVra,prlof to Its Issuonce, also re- � � �HO7 wqTER HEATER "� '� �- : � � � . ., . �� ��qolres the appllcant fo�such perm7f io(ile a slgned slv�e- , - . P[UMBING�FIXT11RE5 �� 1 '� � � � � � �� � � � � ment fhc/he.ls hcensed pursuant io�hs provislons Of the � Gp��rt . � . � � � Con�rottor's Lltense Law(Chapfer 9(commene�ng w�th . '.. UTiLIttCO.NOTfFIE���.�. � . I... ..... ... . . ; . . .. � . . . �SeNlon 7000f oi Dlvlslon 3 of the Buslness and Prales- . ., � .. � � � � . . . .sions Coek)or�haf he 7s exempe�here�rom ond tHe bas�s � . .... ... . .. ......: .. . .. . � . . . for-ff�e�olleged exemp}Jon: Any vlolatlon of Sectton � FINAL' �� � �' ' � �� `� � � �' � , ".. � � . . � 7031,5,by any appl fcanf for a permlt�su6jetts�he appl!• ��'�� nfer on ronE � . , . � � . � - rant io a eivll penalty of nol more thon flve hundred ., dollars(S50D).: ; - iNDUSTRiAL . .�..� ���.. ` � � ' . . .��. .' ' � � . . ':�� .� � :� - ' � � . �I,as owner of tha property wil(do)he work,and� ' wASTE APPROVAI ' � � � � ' � -._. . .._�._ . .. - . the structure is not iniended or offered,for sale. � � �. . . . ��" � - . � . � � - "' �� - � - .., {Sar.7044,8ualness and Probaslans Codei �The Contrar ' � � �� � � � '. � � -. , � � . . � � � -�Yor's Lcense tuw dues not apply to an awner ot prope�ty �i '... . . ... . ,�'� .,. ; -. � . � . . . � � � -� � who b�lids or 7mproves therean, and who does sucfi . . . .��'..... � �' '�.. .. ._ :.�.� � . � work hlmself provlde,d fAaf such improvements�are na� �- �. � , - - � ' � � . � � � � � �� ' �� � ' �inlaeded or offered lor sala.�If,bowever,fhe 6WIdMg or � , , i . . . � ` ' � � '.. " � .�trrrprovement Js sold wlfhln one yeor of comple0on,rhe ' '� ..-. � . . .'. ' -. �� . � �.....:., . . ' .-; . �� � . . . . . .. . ..�:-. � � � � oivner•bullder w111 hove tXe 6urden of proving IRat he dld ,, . . . , . . . . . . � :.�. ;��;. � .' .-� - . - �... ... . . --.��... . �.. .� . . �noi.bWldorlmproveforfhapurposeofsele.J � �' , � � . . . .. , , ... .. � i ' b am exempt under Sea , , , _ _ _, . .. 6&P.C.for ihis reason ; . ; : _ __ _. _ . . . . . .. �� � � Date � . . . ... < . . _ . � . .. :� '. . ��'.. .. ... . ..... . ' . . , . .. � ' �. Owner INSPECTbR'S NOTES „ ,,. ' ,. . " , ; � I � _ � , • . _ _, � �'' : p ,. I'� . . � . . , R� � . �,, . . � - � . . � . � ' � � ��`t . ' . � :. _�.� . ' � � � . ...�. � ' ... . . .... . . .. �.' ,.... ..,. . . p .'. . . . .. .. � .