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HomeMy WebLinkAbout0785A (4) r ._._. ._ ..._ . ._-. _.,._, .. ....... .'..., .,. �,.,..._ ..��.,....... ...__.-. . k' � �. W RKERS'COMPENSAiION DKIARATIQN , .A,ppL�CATlO�I �OR PLUMBI�NG PERM#T ///� '''���� � � � I hareby,offirm ihaf Fhave a cartifimis of consent to�elf �� 78A867A , _ ,: ,., �� � �... insvre or.a certificate of Workers'Compenaation Insurance, � CE 617(REY.8/68) � "� '�. '` .��. ...,r . . , , � or o tert#ied topy fhareoF-(Sec.�BW,lab.C.J �� .. '� '� ���� � � � :., ' � � ' PaII`r„�ky. J�L��r�po�Y �lL�E.t'�C'.ft�<4 �it, COUNTY OF LOS ANGELES�, � ' CEPT: OF'PUBLIC'WORKS _ "d' vl ' � �� Certlfied`copy is herehy formshed�.� ' �.�' . ...� . �.. . ..� .. .��. . . .: .�. . . � � FOR APPLICANT i0 Fllt IN(PRINT OR TYiE) - BUILDING or (� � ,Cenified copy is filed wnh fhe oounM bo�lding inapec ADDRESS �O � -t � ' 4 ,..;t(i,/ondep���qr�t�ment .,. , l _. . ;. . NUMBER ��,PI%TUREORITEM � ���E . .�IOCAIIiY ...�� ' . . ,i . Date'_O��-��APPIiGaM �1�YKL2 �Q �.. WATERq.OSET . _ . NEAREST �� �. CERTIFICAT�OF EXEMPTION FRQM WORKERS',� � � BATM NB , � ��S ST• - � _ . . ,.. _... � �. . �.. - CQMPENSATION INSURANCE ' . pW�R . . ;. � , ;.,: . . . .,..; . �� (This�ucfionna�dnotboeomplHedHiheworktnrolvedbr :. .. -.._ . SMOwER�.,. ....�, . ,.�_ . �14 � ( r�. 1be permlY is for One hundrod dallats.(5100)or I�ss.) � . tAVATORM � � ADDRESS ./� �C I�p �� 1 eeibfy.ihar in:.the performonce af.the�work for which thix . � _ • � . �. . PermJ Is msued.I nholl not emPfoy ony person in any mOnner . SINK �. Cltt .� �..,__ __ 7. ���;�....SEI.N05'.'qy� �"'• so as to become subject to ihe Workers'.Compensation Laws. -- - .,�- r noY� i ... ., '. : ��, - bISHWASHER CONTRAfTQR� "'� y y, P�. �ata. .. OPPIitOnt . :� ... '.�� GIOTHESWASHER ..:. , _ . -... , '... AUpRESS:,.. ' �s� . . ':� g Np7iCE.TO APPLICANT: If..after making ihis Cenifitare of -� . . . ... {,q-jr-c� �-. .•.�...� ......� SR'� Exempt on,�yoo.�should.�hetome sub�ect �o the,��Workera' �-�..��SWIMMINGPOOL RECEPTOR . .�; ` . . � k fompensation.piovisioos of the Labar,Cbde,you�must forth- � . pn S �'�1�.N '��,a,;.�"...�+ � �� . 8 'w�nc �omply wifh wCh proviswns or��his p0rmit�ahali be . � u+WNSPRINKIfRSYSTEM �..STAh r/ �a ���� x� K, 'deemed rovoked. .'`�_ �, ���.. . � � . WATERHEATER . � ,�IICENSE�NO..�� �--9 y d,-._a� �dA55 ..07' �'� . yh tt�� UCENSE�CONTRACTORS OECLARATfOM DISTRICr rio. wt Eo BY f Iherebya�firmtfiatlqmliceliSedWnderprowsionsGiChepter4 { GAS6VSTFM �� OVSLETS ��� ' � M.,,�n� �� - mencing�wNh Sectioh 1000)of Dlvision 3 pf tF�e Business - pUTIETS OVER . -.- . .. .._ , . �. � � � ��+"-'�--"vC._ � � � and Professions Code,and my litense Is{nfuil force'nnd e#ecl. 5 aER SYSTEM � � fINA ,�1� � � . pArE �y�, VAiIDAT10N � �; License Number�Z'�1��3 Lic.:C�Css��,[Ly�.�. . , � � � ""�: ��. ��-.. �, Y�,, c�r flNAI S F Coniratfor� l�ra�xti� O �--�7"Yf'�, gy � � � ��. ' .4 em exempt under Sec. - , . , ,, . . y� �. .� ..8 8p C.for thia reason. �. : . � � � .� �..: � �� � , . � �@S Plan Eheck fee-_ . . � 3 Date: � .... �Signoturo.� - � '��� . . PWM9INC'a PERM�T ISSUING PEE t!. I� �,j� . � . .. . TOTAt FEE' ` ...._. . - '�: :... . -. . �' . Plan check applicant . . ,� � � . . . . , . . . � � StNGtE fAMIIY .�i . . . �MOME OWNER-BUILDER�ECIARATION ..... �.. Name..�� . . . � .. . . . :....��. :� ....,.. .._. .. . _r. .. j� �� I hereby o8km thar 1 om exempt from the Conlractor'a Llcenae.: - Add�ess' .....'.. - ..-- .::� ' `� •.�.. . :�.�.- �� � � I.� �. Law�for.rhe foflowiog reason(Seci(on 703I,5,$uziness aod - � � � �� -� , - . . ' ' � � � �� - �.� � Professions Cade): �..� . �� �. - � City ,..-... � '�,�.�. TeL.No.. . ,..'. . . -�. . ...� ; . � �O 7 Q Jr' A.. . .. �� ❑ �.I,as owner qf fhe properry,wlll do tAe work�and tha- , ... � . $��s � � i�... . � siruch�re is no�intended or offered for stile(SecHon- .:.► �; �;.7044,Business and Profeasions Code). � � , . � . . . . .�. . .. �.•� ,� ��� � �� ��� � � 'LONSTRUCTION LENDINGAGENCY� ... .. ...,.. �_ . , .._. ..�:.. �. ..!.�� ._,.. �...._ �. �� . E. � f bereby aK�rm thar�here ca a eonstrudlon�lendi�g oqeney for�. . �� . . -.. � . . . � .' . . � • •�• � !�5 Q�c=a.� � .. �,.� .ihe performance of the work foe which�his permit ia las�ed������ ' ��.�- -� �::� �� � � ��-.- -���. ,�-�. 0��t 7 4 8�7-� �� ;:. '.(Sec.3097.Civ..C.). . � . . � � .��� .. • . ,,.. � .�_ .... �..� ., ..�,.�.:. . ... . . . .�.. . �,.. .._...... � � � �. jl � tender's�Name � ' .� . . . '� � : . . ...._ . ' , : . . . . � .. : . ��, . . . �_ �. . ._ . ... ,.. � 4.. . lenders Addross� ... .. . � .:. . 1 eertify rbot I have read this applicarion ond stare�ihat the . . �..�. . . , ... . . . � , - , . '. � �, i � above information!a corcetE i agree ro comply with oll Counfy � � . f: � ordinances�ond State Inws re9ulatin PI�mb7n o�d hareby .. ..., . . ,.. _.;� �. . . ..... � .; 9 9• �- � authorize.eprosentotives of�his Coun�' ro enter�upon the � ;. .. � . . . �. . �/ ea. SEE REVERSE PpR E%PLANATpRY tANGtlAGE - obnve eotioned prop rty for inspection purpos i �""/ �.:�.� ; Siynafure of Permittee � � ' . pote .���:� � :��.,, �.�: . . , .. ��. � '�.. ..�.�� . S . .. . . . . . . . . . . . .. ... � ��� .. . . . .. _� .. � �.�� .. . . .. � .� , ,+.� ." . . _ I , _., ..... .. ... .. .... . .... . � . � , � � APPROVALS�. - DATE �.. INS1%�EC�TOR'S •'. " _.. . .. .... _ .. . ,..QWNER-BUILDER DEGLARA7ION --..� . ,_._:_ ._.___.-__ _._.' _ �SIGfRATURE � . � � ��-- -----��-�� � � � � � �� � I hereby a8irm that I am ezempt�hom the Contractor's ticenee � �. TEMP.POWER POLE � � � . � . Law(or the.following reason.(Ser.Yion T031.5,;Bysiness;�ttl . .... . . ,_ _ .. UNDERSLAB WORK;_.. .... _ __ ._.... . ' � . .. � �. � Pro)essia�s Code1:Any citY a camty which.reyuues:a Pamri[ i :._ ... ._..._. - _.-__.:. ROUGH CONDU4T �- . . .. � . _. . to consWet,alter,irtpiove.tlenolish.a repa✓arry struclwe.P'�a �__.. .�... ._..._.. _�. , . . �.,2o its issuanca.�also'rc�Ues�fhe a�pt,'cant lor such P��+i fo-1Na .�.�._..��.� _�:....: .. .._..' . r - WIFING ... . �� ' � . � asiyned.statemenl�Hrethe(S�ficanSedPws++�t�.ta..tha�p✓ovisions . ..� .,. .. _-.-�.. ....PIXTURES ._. .. . � . ._.. ..� __._. . . d the Cmtracrov's Liceroe Leov�(GhePter 9"(conunaxirg with ,, , . . . „ � . ... Section:T6lJP}d�Divair»3�d the�&siness��atad�RoMssiG'+s ;�.�.. _. -_:.:-..��POWER�AUTHORIZEO - �_.._ __.._�... .___ . . � ... ... . Cafel a�tt�t he..is Bf�K_.tltereh'rnt.�antl�lhe�Yess�..(p'.the . ,:.... ..._..__ .. . ..__. UTILITY CA.N071FIED , . . . .� aiFe�d exerry�ion. Any.�viofatir»ot.SeGtiai 703J;S�.�by�y . . . -�� appirCant lor a:;}ermrt:sulyecfs-the��ficant�.b'a civit Per�aitY �� _. .._ .... ._.... .....__.. .Flt�IAL. _.:.. �y2tCr�0Yl FY012t . ._.. .i ,;� . ..� . � of rrot mae�En�or�fi"ve�Ula�dred�dotkvs fS5001:� ._ .... i � � . . . � ' �. � ❑I,as owner of the property witl do tlie work,and the • NOTES ..._.. � . .� ..... .... . . ___shucture is not intended o(�o€fe�ed�fQr.saie._. ��:. � -__ _... ... , _... ._. ; . . �. : .. .. , . - . �' ' .�'. . . . , . . ..�(9ec::7044,�BusinessandProfessirnsCade:�:��The'Crnfracpr'S � . ..-� . . . ��ticp�se Law o'ves not aqNY ta e�'awaee�.W�P�+tY w(m(uilds � <_ _ . _ _._.-. �.. �.. � � � . � . .._._ ' ... . . . . -. , � _ . -or'improves tlf�vean.��arM who daes�such�warir himSefl AloviG4d " ... .. . . _... . �. . ... .... . . . . . th�SUGh impOVemetti���ere'not kKendeif�Cr oftE'etY(a�suk.!l, : _ ...-_: . ' �.... . ..... � . . . . ' , . _...�:,. :. _ _ .. .. . ' howevcv��the�6upiiin9 or irz�iovemeM rs soki within me Y'�ot � , .. ..... ...: �• . � _.. . - . .... .. ... .. . . _. . . . - corry�ieYic»:Trie�owner-'t�i�dcferwiAhsve�l£leiHudcn-otp.wiryUaat I . �, ........� ..` . ..� ......... .... :�. ... .. �.. � . . . . . .. .. �� ...� ..�he d!d nor bat�a or�G�m��kr rhe purEwse or sa1e.1 ... ; , . � ...'� , � � . ..... .. . .. :. . .,.. . . ! �+h . � ... ..." , . � . . .- . . � � _ .. �i] � . _ � �, . � � . ... .. . . �`�- . I am exempt urider Sec �.. .'. . . �..• E . .. - -- - � - � � � l , . . . . . . _. __.. . -,. . _.- ' , -� . -... � ', ' . . .. . . . ._�&P_C_.focfhis.reason , �. :. # _ , ,: . . . , . . � . .._ . . . . . � - . .. . � �. . . � - , . _.. _. _ ._ _... . . .. � , . . . - . .. . .. ... .. - . . . . . . .. . _.Date� � � i � . . . . � � Owner . .. . .. �' �.. .. . ...�., �. . . � .. .._ .... . _. . . .._. .. . _ � � . . ..._ r� e . . _ .. . . . .. .. � ' �,. . . . . . . . . .. . .. . . � .. . �� � 71d0� �101�3dSM , Na d N' p' O �' �-�, � ` � � ' � � � (`4' �v � �. r.� V Z . ' . GJ� � � .-, ��-T �I . ,. L` • �' ` J a � � Fa O • • • •- r } O � � - c;y� • . s m �.CY7 �; � 'V'� °1 � m 7 , �� — � o - � !� o c'� > , z Z � ,. ` � � � � W . I— � " � _ ' � a G N ~ � r � � �- � , � , i � LL c� IS � - `� � `� � i � � � Q =' � c� � �" � � � � � !'� • � � o m Z � (,� � ('f1 t?� m r //L��1� m . � � .N� (t¢ .W U�y a � �-U � } ZZ ¢ ¢W ¢ S .. � . ��. ' . . � � � Q V ap z� �p F ga Qp. � �a O F= Uw � �Z¢ . 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