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HomeMy WebLinkAbout0865A (4) _ WORKERS'CO�YPENSATIONDECLARi1TI0'.V. . .icdsa�n. . . . _... ... . �. �...,__., ._. :�. . , _ .. _ . _.. . _ .. .. . . .. . _.. ... ,. . _ .. .,,. . i hereby affirm that I hxva a'certificaJe of consenc to se!f .�ce'e"oir=-ea;�� APPLICATION� FOF2����I�LU'M�B�T�I�I`G ���N�TI�"�"W�..�µ�� y insure,or a certificate of Workers'Compensa[ion Insurance,or a certtfied coD1'thereof(Sec.3800,Lab C � COUNTY OF LOS ANGE�ES BOILDtNG AND SAFETY Policy No.- -- Company-- . � D Cer[ifiedcopyisherebyfurnished. FORAPPLICANTTOR�L�W(PRINTOR�7YfTE) ' BUILDING ��,, � � � Certified copy is filed with t c nty b ilding in5pection NUMBER F�XTUFE OR ITEM S FEE A'�DRESS ��I � % �� depa me t. - WATERCLOSET - LOCALITY ,��__ ., !> � •�L ➢ate .4pplicant NEqREST '1• /y ' � BATH TUB� CROSS ST. ��O 1R��d�„ � CERTIFICATE OF E:;En4PTI0 �R0�1�VORKERS' COb1PENS.4TiON INSURANCE �� � - SHOWER - � OWNER � � s " LAVATORV MAIL ) (� �(This section���need riot�be complete3�if the'�w5ik�imolv'eil ADORESS .a(� � � ` �y� Sy the permit is £aa one hundred dollazs (§iQ0)oz less.) SINK �irv + u TEL.NO.� � �.."Q i cer1iFY that i�Yhe performanc=of the work for wh�ch this DISHWASHER ;^� ��, .n (`��} �ermit is issued,I shall not emp]' �a�ny�persori in�any-inanner i�lJ CONTRACTOR �as to b co 'subject to the � ker' o pensa[ion Laws. CLOTHES WASHER j , qDDRESS / q � 4atef � Applicant �y'�� L_ r� � � SWIMMING POOL RECEPTOF I 'OI'ICL TO APP"LTCANT:'If;'aff� making this Certificate of � CITY ` h TEL.NO� p_ � y zemption, you should becom subject to the Wurkers' LAWN SPRINKLER�SVSTEM � : �' ,1 ' I STATE L I C. � 'ompensation provisions�of ttie Labor Code,you must forEh- (� r >ith cOm 1' with such WATER HEATER � , I LICENSE NO.�[ � ,g CLA55 G. p y provisions or chis Dermit shail be I -� _ :eemed revoked. � DISTRICT NO.� PROCESSED eV GASSYSTEM OUTLETS � '� i. � LICENSEDCONI'RACTORSDE�LARATYCfi1��� � � OUTLETSOVER ��P� ���r},y`�., hereby affirm that I am licensed under pme75ions of Chapter 5 PER SYSTEM - �(commencing�vith Section 70Q0)of Division 3 of the Busi- FINAL �ess and Professions Code,and my license is in ful!Force and DATE �d(�r��� VALIDATION £fect. r� � � qY �J�J FINA��t� �icense Numbee Lia Class_ B,, �,�� Contractor Date ���9� � � I am exempt rom the Rcensing requirements as I am a Plan check fee licensed architect or a registered professional engeneer pLUMBING PERMIT ISSUING FEE$ � ^'+"'�, acting in m3' professional capacity (Section 7051, Bus- iness and ProFessions Code). � 5� - � TOTAL FEE C.or Reg.No. Date -' � - � plan check applicent � HOtiTE Ol4'NER-BUILDE1t�D$�G`liARi\TION� " Name �herehY affirm that I am exempt froin the Contr2ctor's��"� Address �ense La�y for the following reason (Section"7031.5,�Ausi- pity Tel.No. r=V���� §s and�P�i�ofessions Code): � I,as owner of the proDerty,am exclusively contracting - � #`� " ° • " ' � with licensed contractors to consfruc4 the project � � � - & � (Section�7D44,Business and�Professions Code).� � � � ° °� � L�n -! CONSTRUCTION LEIVDTYG AGENCS' -. . . . . ..- �- .... .. ._ . . . . ...__: . -. , .. .... �.. .. " .'. ... . . _. � �u o � i l:^�i� =re6y affirm that�there is�a�consiruction lnnding agencg � � � � . . . ;the perfonnance of the work�for whicti�tFis�permit is� �-� � � � - �� �� �� -- ' -� � - � �'- �-�� �� � �� ' � �.C I `�� '=_d(Sea 3647,Civ.C.). . . . . .. . . . . .. . . . .. der's Nxme , , � ier's Address � � � ' - . .. . . . .. ... ._. . , . . . . . ._ . . . . . . . . . . . , . ., : . - . . , '.,.� . .. : . . .. _ .. � . -.-. .. -. ... _. � . . . . 'rtify ihat I have read this application and state that the �e information ia cOrrecl.[a%ree to comptY with all CountY ...._ ..�._...,,.. . .. ..... .. .. ...__. . . _. _ , ... . . hances and Stxte laCvs regulaHng Pfumbing,�and'Siere6y - � " SEE REVERSE F6R EXPLANATORY iA!�GVAGE �� brize represen[atives of this County to enter upon the :e- ed oper[y forinspection purposes � �� � � - - ��'���- ///��i �ynat e�f Yermittee Date w i ' . ' ... - � ' ' , � - —� _��_�,m..�__._�....w_...�__..�..._..�___ '�. itiS?ECTCFi'SN6TES ` , " ; ."�ye'"z�'2-$FII�.I3��[9ECLt�eZ:.TTC3(d" P.P?ROVALS DA7E !NSPeCTORSSIGNAT:iRE �,._.,_a..,�.�.._..._._._..,,___.u......_._.._.__,.__...._., - . _ . . . . ... _. .,.. ._........... . .... .. UNCER SLA9 iNOi2K .. """"""'-' ' liOUGH PLUMBiNG � � '_ ' . ..... ..... .. '_"_"�, ' -=;''Chy�afi1yT11[V58'.�i 3M':%�ill�t SfOtri Y�?C,OnhaL4Ct�5 "'_"___s_` .. ...............�........,..:...,.........,....._...._...,-.:�... . GA3 PiPING i � . ...plces?sfi L'au�Tr�r 4N��e:oilo�cing seasen 1Secti�n iC3L5. �:usiness �rtv+ F:ofe,sions Codz/: Any ciry ar eau;tt�� -- — .'-- ..:'----- _.__... . . . GAS,V.EN7 �; � "��' "'" '� "� ' ��i27cle mquirVs 6�permh to constnse7. e?ter.�rmprave, HOTN1ATcRHEATER . . . . — . �._.. �._- _...... .._ . . . - �. .. . � . . ...... . . Geino17.4.�-,it! ' � ;ypair atay stn.�cture,or,cr tc its rsaum2re, .. .. . .._ ........:---..._---......__....,....�_.__ . ....._ �. . � .., . —� � �lsc re�Fiir'e�*.`th.e'�7;pliranr jor swch p^rm:t r� fi:e a PLUMBING FIXTURES � , . ' � , � . --�-- __._�_._._._...�_. .,rate er, ---fi-.— - . _ . .. . . - . ;rga:ed. '.� r!e ; tr�at he is lirensed,pursu¢n= to the ....�..... ,.,_.. . _,.... ....... .-._. . . . casTe57 � . - - - � � pr6vrsraris�of tke'�Con.ir¢ctor's Lecrrse La'w`/ChaArer 3 —-- uT�u`iv co.rvoTi�teo � � . � : . . .. --- - .._,-----.= - - _ (com:nencing wre'n�3e�7F01: 7OCOJ af Bi��ision. 3 0,8se ....._.._...�_..._........ .._ _ .. ..�:.._...-•�rid..,.�r`oje.^"sious"Cod'e,� �r thar he is ezen,t o �- —� - uusireas a -- � n d !6 - ----��-•----- - �herefmm.a:td tne hc��s yor,the nt!eged exempricri..sny FINAi� G�6LL8/i �f2�V�1492i - . - . . ..,., . ..---...,...:...,!-....e .� .. ..__.... ' rio.c?ien.or Secte3n-70.?3.5�y arY urviicaiit iora per+nii .. . '. .: . . ...'.'.� - � ,.......—. svh�ecrs t.he ap�l"uct�t zu a civil pereat:y of not mor�nc�n wougraia�----- . ----- �- -- � . . ... . ---� . - ;�v.ehundredJoilare;.SSGOj.: , . ... .. ....._.. wasre aapaoV:nL� .. , ' -----�----,�_--...-------- .._ u i,a>awnes o?'the p[opecty�vilt du the�sorx.anc7 .. ---...--. .... . . �ti4e s:i�acture is a�oE in,rie3ed cr offese�i-`o:saie. .. _ . . :. ..'.. : - ..,f. . _,_.,.__ ..�,.�._.._._..._.� ;Sec. %049��$us:n�sv 1nC,Frafe�sions t7ode:.,i"ne£'am . � ....... ... ..__, .. _ . ' . ...___._ _�_._'_._ _._w, .....,...... .. . . . � ' � . •raclor:r Li��:rsnx7,aw does'riot aDF`3' to`¢n��d�aner oi ".- � � . ' � . -^--�..__�___. proner.y.who 5uftd�cr imyrbvzc.thereun.�and�a�ho dees . -- — . _. .. . . . . :_... .. . � � . . - such'�:�ork. Niriise;f:�prcv,ded rNar ruch improvemenis . . ... � are nat i;a[nnded�or o�fered Jo!saie. :j &nti�ere�, the '' � - - -.._... ...___._......,._._._.._�.....__.._._. . . � . . . . .. . "r.uiidircg�ev imF�ror�fnFr"�s �;s sold wi?hir one �zar oj ,_ .;,'. .. � � ---._—__...—..�_.—,_..._..... —.�. rnmnlatir.r,. the.owner-esv�ilder ;vr(i IIL4e .'JtP burden . ....... . .. ..... .... ........�.,...... , . . . � - - .�f nrcvrng tluit��nz �i�1"nti� 6uild or r:repro.e fur the . . . , .. . ' , , G71P..i8 U SQ72. . . . . . . .. .. , f'�_ �. 1..... . . . ..... . . . . . .. I 2s:i�?��empt uE�ci'er 5ec. __ , _ ,. —... .. ��P .. ....._... ....,.. ,..... . �.for gh'ss rea,on, � . . , —. ............_.....-. . . _.._ ��.� t3wner..,_.__ -- . ._ ..._...�........ .......,»w....r._...W.....__.,._, .u� _.. . ..., � . INSRECi OR'S MOTES .,.._........ ......_.....-...............,«-».....,.,»..._._ .._..„.._.�......w....,,., .-..-�,�..�-..'.-.,..,..,, ..,...-.�.�_,.......�..