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HomeMy WebLinkAbout0947A (5) , _ . _. .,.. . . -_,_, Sj .,,�WORKERS COMPENSATION�DECLARATION � � �- �ppL��ATION FOR P�LUM��ING PER1V(IT�- � --� � � �- �� . ',� �,:+F�ir+a*»..a�r.:.; -:: :''20-0026 OPW ni87 � hereby aff rm thot I ha e a<e t f cpte of co sent o se f n; �6q667A � � � ure oracerlifcateofWokers Compensauoninsurance ora CE817(,REV e Ab)-,�- ��'��' ���� '��-���- ---" � � � � _ .�_.._. _.,....... _ ._. cert f'ed copy�thereof�Sec 38D0 Lab.C � , "' ' GQUNTY OF LOS ANGELES DEP7. OP PUBLIC WORKS _. ... ., _ .,. ,,.�.,. ,....: Policy.No. .. . ...-Company.-� -��� .. � � �. � : ... . . . .. ..❑ Cer fiedcopy shere6yfurnahea .,:: .. . . .,. . : ��.,. .� ..��. � _ .. ...�.. . ..' . . . . :..� � . .. .-.._ . . Cerl�fied co FOR APPLICANT TO FIL.IN.iPRMT OR?YpEj 3U LC'NG f ry /^' o py is filed w ih the couniy building nspeciion . ADDRESS �1�y S C.-�6 -S(Qf L/94 � � ' ' NJMBER FIXTURE CR ITEM FEE ��q�ITY y�n aeportmertt. � @ .. . . Date �.. , 'Applicant .� . � . �, WATERCASET;TOILET�i :�' NEAREST'- ��A d1u ,7l� , anrr;rus , ceoss s?. �'j 3i ^ �i +v � Pi�'�'1� ' � CEI�TfFICATE OF EXEMPTION FROM WORKERS' - � - . . . , � ��. COMFEIJSA710N INSLIRANCE `�- � �" � SHOWER i � �N'NER C�� :��; (Th s sec�wn,�need not,b�e comple+ed-if fhe work involved 6y . � � �� MA!L '1h¢p�rmit is�for one hundred dollors(5700)or less.) ' ��a,VATORY . � �i � � qpDRE55� � 1 certify that in Ihe periormance of ihe work far�wh ch this�per- � SINK r;Tv TEL.NO. m�t is issued,I shall nor employ an-person in�a��� �nnerso � � I � ;-asYo 6ecome subje�t to rhe Work rs'-� e � � � � i Laws p.��,5hWA5HER I I .�. . . . .. ......... .. .. C�N-RACTOR��(�y� .. . Do � � Applica � ' CLOTHES V�ASHER ! '� �� . - I�� ... .. ... . .. ... . ... .. .. N6TI�E-T 'APPL CANT:If�,�after ing ihis Certific,afe of x-. ,SWIM,MiNG POOI RECE7TOR � � a�7DRE55 . e'riipfib� ou sho�ld 6ecome subjed ro the�Workers'Compen- � . . C'Tv '7Ei. . sat on� yisions of th�,Lobor Code,you musf forthwifh.comp- �qWN 5PRIfJKLER SVSTEM -� .� ly witH such provisions or this permii shall be deemed revok- � � SiaTE � � � ed .. . - .. W.ATER HEATER � '�_�.CENSE NO-. �� CLASS..�. .. .. .. .�- LICENSED CONT,RACTORS DECLARATION ��-� —>- � � oisieici!vo. �aocesseo eY � � �� � I��he eby dffirm rhat I pm�licensed under prov s�ons of Chapier GAS SYSTcPd._ . OUTL'c?5 I � /� .�-� . � � 9(commennn4 with Section 7000)of D vision 3 of tl7e Business� � OUTLETS OVER� � `��-���� �' 5 PER SVSTEM - ' I � . antJ ProPessions Code,and my li<ense s full force�dnd ef- � FlNAL � - -� � Y fe�t � ; VALI6A710N . d _ . . .. .. �'�4�G _ Clk=t� � � fs�7 oaT — .�. U �License Number � L c Closs . � - � � . . � � � . � � FINAL � � .Coniracfor_"- , :``Dote � . gY � � . . � � ,� I am exempt under Sec � _ �y V 6 8.8P C.for this reoson � � � � �1 Plan che.ck fee , Z �- Dote - -- � �� PLUMBING PERMIT ISSUING FEE$ �� s'?J ' _ S gnaiure . .. .. . . . .. TOTAL FEE �� f ' ""$ � . �to � � �-SINGLEFANiILV ���-�-�-� � - " �-" � � . . HOME OWNER-6UILDER DECLARATION ��� � � Plan check opplimnr� e--�---'.-?-`����~. . . � , �I hereby aff�rm that I pm exempt from�ihe Confrp�tor:s License ,. Npme - �•- - ��T�---�� � ���- ���-� ��- • -�����-�- � Law;fo[Ihe following reason (Sec,tion7031�;5,-Business end � Professons�CodeJ: -� � � � � Address -- ' � � �- � � - �� !U G���� . � �. ,. . . ,� _ . . � I,as owner of ike properry, w�ill do ihe�work ond Ihe Ciry � ' Tel.-No. �� o F � � � siructuce s not intended or offered for sale(SectionJD4d," � � . . . . � � Business�and Professfons Codel.� -� - - _ , � � j e c 5 �.,��r �CONSTRUCTION LENDINGAGENCY� -� � �'�� "' ����-��- � ��"�� ����" � �-����"�� "' ," ':� ` , , -- I hereby affirm tha�there is o construction lending agency for � � � ' " ���f-���;j� �� - , ihe performance of the work for which rli,is permit is issued � ��- ����-�� ���� �� � �� � � ������,� -� � -� � � � � -� �� � � � � �� � - (Ssc.3097,Cf v.C.). . � � � � � G�.i �-����. � � Lender's Name . . .. :.� . . .:...,� . . ...�. . � _._�. .. .�.. . . .. �� . � . �� ... . . - . . ; . , . . . . . . . . .. . .. . . . . .. .. . � Lender's Rddress , �. .��-_ : .. - � - . � . ��. . . _. . .:... . . . � . -.` . . �� .. .. .. ....._. _.. . :,. . .. , ..... . ...... . . �... . . .._ ._ . . ........ :,:... ..,.. . :.,_ .. : . . -I cerrfy that I hove read�hs�appliwton and itate that_ihe ��.� . � � .� , �.�� � .. - � � � - - � , � obove nformpt on s correct I agree to comply with all County � � � ordinances a.nd S(ate laws,regolafing Pl�mbing,-and hereby � � �du�horize`�representoi�ives of�)h7s Counfy to.�enter�upon�the � _ , . . dbove mentioned roperty for inspection.purposes.., �.� �� . . � . . � . . � � �- � � i�..�� SEE REVERSE FOR EXPLANATORY LANGUi4GE . _. . '� „�C,y,� � ' . . . ., .. . .. . ;. .� . . . .. .. . � . . I t of Pe �fie Date�.. . . .. . .. . _ .. .... . .� . . .. . . .... _ . . . . . . ... P ,: : . . .;. ; � ` ;::�"-"'=• iNSPECrr`R c^dt)T�S � . , _ . OWNER BUILDER DECLARATIOi� _._.. ... ARPROVALS � �ATE ENSPECTORS,SIGNATLIISE „m._„�,,.��_,.m.,,.,_,. � � ' � � � �� � _� __,.:....,,....,._..,.�....-.... _ �._hei'ebY afflrm�Pbet I am'ezempt fiom ttie Contrect"or`s-. ,.,..,. UNDEF SLA9�WORK - _ � - — . .-.... - � � . ........,_ wing rea�on (Secbon�7031.5, ROLGH PLUMBING --........ ... ...._,......._...._.._..,....__...,�.._..__.,_. . . 8usiness and Professl6ns Coa'e). Any c!ty or cpunty GAS PIPING � � � --.— _......._.„ ,_.,.,,..__.. ,,....._, ..which.requires a permif to Construct, aJfer: improve. cas veNr ' demolrsh or repalr any st�vcture,Arbr to rts issuarrce. �Har waree w eaTEa — .. ,..,,: , ,,. ...._....also requires Yh8 appliCant for such perrrrrt to#ile a signetl P�un�eivc F�xrueEs� �- � � --��--� � � ' � � � StBtemenP�that he Is licen5ed Rursuant to the provision3 -- , , ��___�_. _. , ....:.. ._ �.....,. . .oftheQontracfor'sLrcanseLaw!LY�apter9(commencing cas rsj. ` ' ." : , r wiih Sechon 70bbj at Division 3 of the BusMess and Pro- unurv co.raonFieo _ ,_ .. �T,_.� . _.,,.,_,„_ ,,,., _ fession�Cotle)or that Be is ex,empt th�rafiom and the _,�_.. . . _ .. • basis for the allegedaxemption:Any violatron oi Section . ., — - .. --�,�...�,w._ ,_._.� _7031�5 tiy any appficant for a permit subjects the appl'r F'^�A� �nt¢r on�'ant cant to a crvil,oerraify of not more Phan 9f1�e hundred _ _ _ .._._. ..�....._ ,w;..�.._.. ._,__....�;�.,aaqaPS f�oo1. : � . ..... ...::...._ ���1-as oir�ler of 9he PeoP�Y wi11 a�ti96 wOrk,ana the IN�USTflIAL - ' ' ' WASTE AP?ROVAI. , _. . . . . .. __.,._._.._.,--c.�^ ,.........._. , ....._...,,�.. ,,,_S41UCtU�O i8„�Ot I�tB11tlBtl,6f 6ffBf8i1 fOf S81B, .J ..... _ . -+..«..._......._... _ , _\ . fSec.7(�4"4",8usiness,ad�rafessions bod`e 7he n(rac- _,.„_ ,,. ,,,_�,,;,y� tor s License Law does not apply to an owner of property + , '� .�4.-- ' who�tiu�Ids or impioves ihe�eon,ant!who does sucfi work ` � ' _ - himsel f providetl that such impravemants are not intend- _,,... _..._........�., .,. . ,..._ .. ed'or oSeretl for sale.If,nowever,the building or im- —.. ..._ _ .,.,..__.�._.. ._....,„:.,. ,.A..._,�_.._ provement is srold witltin are.year of completion, the . ownei-Duilder wif!ha've Plie 6urden ol praving that he did nof build or•'mprava ior the puipose oi sale.) : ,._.. _..� .,�. ��„_�. .�,.._.__ .,�3 am er.�irgptun�ar Sec:.. . :......_ __. .,__... .._.. -- . . ,,-.�,... .,.:�:... _.m,n,w„.�.,.,..>:.,,_.. :.� ,:.. .�..�......e:.... _ .. .... ,�,.�...,..�,,,.._�. . 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