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HomeMy WebLinkAbout1346A , .. . . ,- _ : ,. . . . _ � . ...�. .�,_,,,..�, ,�-.: - lti��l� r�[c,-n - ,. �-k,�:>;��.��_.,.��:. �. .. ... .. , WORKERS COMPENSATION DECLARATION APPLICATI.ON FOR PIUMB.ING PERMIT I hereby,offir�fn t at .�-- a cer•i�icate of consert to sel'in_..:.�6A6G7A Pw a�87 . . >. ... ...... . .. . .. . . .�. . .. ... .,.: a ., _.., - ... .. . sure,or a<ert 4 c te of Worke s Campensation Insu an[e,or o � �E 877�REV.8!B6; � �e�tnfi ed cop ihereof(Se.3800`,La6.C.1� ' � ,�W.1� �rb„��-a� �}��I};�-�,t� ��� C�UNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS , Pol¢y No. Company . . ... , . . . ._ ._;�, �....4 , . ,�.r.,�. � . ,, . � Cert fied copy is hereby furnished. �-. - . � ., : . - . . . ... . . ... . .. '^ BUL�iNG .��'�: . . . � '."•"`.""°'�'" .. ... . .._ ` .,_ , _ FORAPPLICANTTOFIILIN PRNTOB'�PEI�y���� ��S j/ e�����qL S ���� � Cer�t fied co C s filed w th the co��,?T�b�din ecrion WA7ER C OSET,OILET ���~`��"'� � `_ N''�'DRE55 , �� � � � py i y g insp NWdBER FixTURE OR iiEM ���-� -���- «�xG de artment I�(,�i,,;Nfjs � eE LO"ALIT� T���G� e_+� , ..,. . . .. ., ��. ti n CCV2t'• ;PuU.tiT'31�G ..,�. ..• ...._ D�ate �-IX�' � i Applicant � EARESi '" ... . . . . ._....,,. � CROS55T. ,(�LZ� LY�C"r.s.S/N'� � � - -CERTIFICATE OP ExEMPTION FROM WORKERS BnTr!TUB : , ... ._ ._..._. ,� ,. ..,....... - ' �COMPENSATION INSURANGE,;-"�� "'-` '� �� - '"""�`"'-' owvek sHoweR l!'L YI/�',�',tJS (Tfiis"seitioti�need not be co.mpleted if ihe work indolved bY ^�,Ai� .�f. -..--•....,....��........,..-.,<,-.-„•:_-,� fhe permlt is fOr onQ liunt�red,dollurs($100)or lass.) '_AVATORY ;.DDRE55 ,c.a� � f certify�hat in�the performance of the_work for which this er- --'- ' ---"_ "' ��-`"»'.,""'.'""`«_'"`•""""""""""""""„" ^•* P SINK C'�TY TEL.NO. �� �CJ' mii is issued,I shall not employ any persOn'in qny mpnner sa Oc�. ds to become subjeci fo the Workers Compensation Laws. �ISHWASHE2 � � � . ... . ............_..,.. ....o.;:.......mc:._�:,,.. . " .... ,. . _ � �ONTRACTOk L;�� �LLSCiLY.c�S 'y�J� �Dole� - � � �� � Appllcant CLO�HES`NASHER ACDkESS � � �Vm��pLZ �����f���� _. , �NOTICE TO.APPLICANTi�#.after making th�s Certif cm of Ex- SWIMMING FOOi f;ECE�TOR • .. . ._. , ._ ..,._ ,. ......,.w .�..»..4.,.,. `empt on,you ihou�d became subiect to the Worke s Compen- _ _ '�sation rovlsions of the Labor Code,you must forthw rh wm - ���--�-- Ci'Y �✓���r TEt NOGjtf���l(� P . . . .P' LAWN SPRINK'�..E2 S�STEM ....._........,-.,_„......., ,ly with such pravisions or'ihis permii shall be deemed revok- �� �� :"",:._�, STaTE �� r/ �� LiC. -�2 ' . ... ...... . �' LICENSE uC. ��3[� CLASS � V� ad. WATER HE/{TER.. - � � IICENSED CONTRACTORS DECLARATION � � ��- , ���-- ��-� �, ��STkiC7 NO. � ' PROcesseo 5�� �` ���� - �""-�" " "' "' ' GAS SVSTEI.�. OUT ETS I hereby affirm thot I am licensed unde pro Isions of Chaprer � � O ��,p 9(commencing with Secrion 70001 of D vis�on 3 of the Bqsiness CUTLETS OVEa� " '�"" ond Professions Code,and m -cense is in full 4orce pnd ef- 5 PER SYSTEM ' fINAL Y v�� _. .......... t� VALIDATION.-- rea. � _ / 'A1caL ac�z.c4et�Hc7cv> �j oare ! � �� a License Number � ���➢�'� Lic Class C �3� � �-•���� U 1'�t_Y.7k.�2> 1CSl4SW�s-6 eQ}� . . ... .._ �.. ZC fPLrl4�ti� � FINAL 9 Q Contracbr �L'�.f h(5{!-".a D te 3�`3(:' �� ..,. _ ,....,`., "`.. BY 1 < O .. . . . . __,__,_ ....,.. >... . . ..:..:..,,- . . . . . . ... ... U �j I qm exempt under Sec. 6 B.&P.C.for this reaso . . .,...� �•�•.....���.�'"�"�m`�"� Plan check fee , y ., . ai5�!bF, Z . . ' .:..Dote . ....._.»...-.........._...... 'tJ � � � ... �.. , .-., , . .,�,,,,,„, PLUMBWG PERMIT ISSUING FEE$V�� I Signature� � _ .... . _.. .._.. . ... �.'c e c c ., . . .... . ................... �.t....,_.:.. TOTAL FEE ( � -. � SINGLE FAMILY .. . .. .. . .......... .:w._..,.,a.......,-..�`�.� 1 a ° I E.�`J`�� HOME OWNER-BUILDER DECIARATION � Plan check applicant '' I here6y affirm thaY I am ezempt from the Conhactor:s L;cense, Name �� �%�������� �t ' ` ' �'' ���' . ...:. 1 .i.^.{'; '.. Law for the followinq ( � ��� reason Sec��onJ031.5, Business on��� ,. .., ._.,„.,_,�.�.,,_,,,„,w,,,,.,, Professions Codel: Address �rr �� � � u'��U C-���'tr . , . , ,.,.. .+s�. � . ....,acm � I,as owner of ihe property, will do ihe work and,the Gty Tel No - siructurelsnolinfendedorofferedforsale(Sectian7044, - � � - -`• ����- ���• �-�-w-�.Kr-�^?`a����w.+:•.-.�+.�-..awmm+:�.,n�.wr.�.y�.,.,,s.�wwa,,,;,=�s.��.,e,,,,,,.,�,.�.„,:1,�,�,-,,,.,,,;,„,,,„,,,,,,,,�_ Business tsnd Professions Codei.� � -� ' � - ► CONSTRUCTION.LENDING,AGENCY - � �� '� - - � � - - . . . ... .........:. .:.... . .... .,,...,... I here6y affirm ihof fhere is a conshuUion,lending agency for � � ��� � ���� - � � � � ' ��"' � � � � �� - .. ,. . .. . .. . .... ...... .. the performance of ihe_work�for w�hich ihls permit is issued (Sec.3097,Civ.CJ. � � - Lender's Nome � ., . , . � , ,.. . .... . ._... . . ,_,-�.... ..... ...... ... ......,._ ...�.,... .�..._..,..___• . ..... L der's Address - � � � I ce t�fy thot I have read this opplicaron pnd state that the _�•-�Yw.: .�wnw�* wwe �'a`.�.P'�'".:"��_�'n�'`':'°"°�-"`...u"'��,."-'s.° � "",>,e�""""""°'+"-"'r"�"�,,.•,�««,.,�a,-r..�.^�„�.. ,-. ,.,^n:. -,-.*..s,�.-�.., .�.�.�r» . . a6ove informatio s correct.I agree to co ply with all Couniy - �"'�"' ' - ����"� � " � x� �y�' ��x, �. � .. ordinances 6nd 51ate laws reguloling Plumbing,and hereby authorize representoi�e;of rhis County to�enfer upon the a ve-menti d property for spection purposes. � � - � ������ �a _u� SEE REVERSE FOR EXIPLANATORY LANGUAGE . ,. . . natur Permittee ,,. . .. ...__�o�fe.....,,.:s.;.,..:,..w...s.��.•«..w�.«...yc,�x�xe.���.�w,.;>.+w:m�.w,.�;w�m„.n.,..�a.:a�.,,,... . - . . . _ . . . _. � �,.k�»., .,.�.�.�.M. ...w�..,,»,. .:..m....,.....� ,<, ,._... ..,.,.zwa,�e+,.-...�...._......,. ;:_, _ �.�.�;:�, �"y �,..�me��, , ��. APPROVALS DA7F .. iNSPEGTOR'S SIGNA7URE.+.Y i.�� +����`'F�R'���T�S _ Y����, Y�p�WNER SUILOER LJ�C�.�A 1 ION y.... UNoeF SLAB WOHH I h9remy eftirm ti�BP I am BxBmpt trom ihe COnir9Ct0�'s - -�` �---�= ��- ��� �� �-� � �Llaenae Law fbr the fallawin� r�son fSectior 70,?1.5. FOUGti PLt1MBiNC c%y�l�� �i�:�y%�A _ '- 8usiness and Proiessions Code). Any city or�county CAS PIPiNG ' S .< _ °�� whiCh requires a permiP to construe., alier, improve, GAS VENT dB�l6fish or rep9ir any strvC[ure,p�ior to its i5svanCe, Hcr r.�area NeareA ----- ; ------tl 4.��- also requlres the applrcant tor such permitTo file a signed PLOMBING FIXTURES sfatement that he is ilcensed pursuant to fhe p�ovisions - -��-• of'theGbntracfar'sLicanseiawtChapter9fcommencing �ns Tesr _ wit6 Section 7000)oi Division 3 of the Susiness antl Pro- u�wr,co.Nor!Fieo - - --- - � -----,,-�--• isssions Code)or Yhat ha is exempt therefrom and?he � basis far ths allageU exemprion.Any violation ot Seation ,,, - - -� - ---° 70.31.5 by any applibant ior a permlf suDjects the appJ'r =iNAi �eeie�oea�rn,aE - canr to a civil penaJry of nar mae than llve hundred _ .. ..�.... dollars($500).. ItvDUSTRIAL ❑I,as ownsr ai!he propee4y wiil do the work,and Yha WASTE RPP„ROVAL ' ' ' " '' ' `""""'" gNUC�UfB 16 f10t 11146Pid8d Of O}fBYBd f0!8818. --- - -- -- (Sec.7044,9usiness arrd Professions Coda:The CnnPrao- � � •- •�•�-^- ror's License Law rloes rrot apply to an awner ot proAerry who buJlds orlmproves>hereon.and who does such work - -•�^ himselt provided tnat such rmprovemanfs are not interrd- , � � � etl or offeretl/or sale.!f,however,Phe building or im- • provemerrt is sold within one year of complation, ihe owner-builder wiNhave the burden ofproving that he d!d �_=� not Isuild or improve ior the purAose oi sa7e.) , _. .._�_......_............:...............�...,..,..,.�.,.�..,._...„..�..�,,,._..._.�.�..�.w..F_,�...�., . , . _ . ' ' .• . . . -. t�iPS 8%@lifpt U�9d8t$8C. ' � S&P.G.far this re�on _- .F Date ,� � ......:.. 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