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HomeMy WebLinkAbout1273A (6) ..., _., . �... . . , .�:.��k,:� ,. . ..�.;-::t..�.r . ..,. .„.�.�_... _,�,t.�.;.�..�.,�ri_ . . � ,.� WORKERS'COMPENSATION DECLARATION , . , APP�,I�ATION FQR ��U1Yl��'VG �L�MI 1 �I he��by affirm that I have a<ert�ficote of�consent io self �yqyb�q '- �� � �� - � � � � -"�. "<. � j�'�� � �nsure,or o cert f-mfe of Workers'Compensalion Insurqnce. CE el7(REV.ID,'8'.i �� � � � �/Y"�f j�� or a cer�'iea copy ihereof(Sec.3800,lab.C.) � ❑ ,f„��/�69� ��J',T,� COUNTY OF 105,ANGELES BUILDING AND SAFETY,,. Pol cy�o ompany Cert fied mpy is hereby furnished. - � � ��� ����� - j�/7 ,g�� � . ......,,.._... BU!L�ING � . .. �_.....,.. ❑ . _ FOR AP7LICANT TO FILL iN;PRINT OR?VPE) ADDRE55 I� C/L �/ ��(II7� Cerrified copy is f led wi!h the county 6 'ding�inspec- �� � � ' . tion deparf enf. NUMBER F7XTURE OR ITEM � �w FEE `O�`�TY y'/���.^�� ��,-j '` �I /! Date 7 qp I� WATERCLOSET .. .. ... . NEAREST .,. ._ ....,.......,_..,.......,.,.. :,. CER FICA OF E ION M WORKERS' aaTH iU6 CROSS ST.G�� � ' �r� ... _.... . ....�.,...,......, ...._......, �- �- C SATION INSURANCE "�- "�-' OWNER �'t. ��L,Lf1. (TFis sedion need not ba complefed if ihe work involved by StiOwER MAII B. .. ...... ... . :.�.,,._�,. ....._...: . .. . ._.. ' �i 1he QermH is for one Koodred dollan(5100)or lass.) LqVAiORV ADDRE55 .Fi / �.�i�-�--- � I�certify that in Ihe performonce of fhe work for which this � -�� � � � "�'-"-•""�"'��"� � permR is issued,I sholl not employ any persan in any manner SINK CITY � TEL NO. so as fo became su6ject lo the Workers'Compensafian.Laws. DISHWASHER . CONiRACTOR v y� c - Oate Applicont � CLOTHESWASHER A�DRESS ����� NOTICE TO APPLICANT: If, after making this Certfficme of� � -� -�'� Ezem tion, ou�"should become sub�ect fo ihe �Norkers' SWIMMINGPOOLRECEPiOR � P Y I . , Compensation provisions of ihe lobor Code,you mus�for7h- LAWNSPRINKLERSVSTEM ,.�,1 �ITY ��� �� TEL.NO �� with tomply with such provisions or this permit sholl be `� V S7A?E ` '-��' ���""�`�"'LIC' � �%��� � deemed�evoked. WATER NEA7ER �- LicENSE n10. �- C1A55 G�1" . . IICENSED CONTRACTORS DECLARATION � DiSTRIC7 NO. PROCESSED BY-� " � ��'�� ��- "'� ��� �"� ' ' GASSYSTEM OUT�ETS I hereby aff�rm tha�I am licensed unde�provisions of Choprer 9 �Q �� (commencing with Section 7pOC)of Division 3 of the Business OUTIETS OVER � ' � and Professions Code,ond my license is��fuli force and effect 5 PER SYSTEM FINAL � . /, �Jr-Cr� VALIDATION y. Litense Num6er ��"Z lic Closs c �� DATE O � T�7 .-_. . BY A`.�-� � � ,,,���------EEE���w� Date I � zempt under 5ec . .. ..... . <j 2 1,.�ii d a m - U B.&P.C.for rhis reason � � ��� -�•�-�•-����-�-- � �' �� W - - Plan check fee p., .. � . Dote: � . . . .........:.. .__., i � �, ; .�r � " � � � " �' �"'�'-� ��-"'-� PLUMBING PERMIT ISSUING FEE S Q o � � x Z .. ..,. . ... _._,. - � Signoture , � � 6��'��`3 ..,._..........,. TOTAL�EE ' � - . .. .,_..,..,.....»:.. �G,U� :�'� � � ' - - � " Plon check opplimnr � � SINGLEFAMILY . . ..,. ....�,..,......«w........,....w,..,,......,..,,.., HOME OWNER-BUILDER OECLARATION Name _ . . I here6y affirm that I am ezempl from�he Contractor's License � '"'""'-"..",.,,°'"_..,""""",""`" Law§or the follow�ng reoson(Secnon 7031.5,Business and Address Profassions Code): Ciry ..... . .........��7e1.No.-Y���.'.'�TF,...•�e�•� � . .. .. _ ..__.,......._ . ,.:......,.�,�...,. . ....3:...:.... . ..::....».:., . I,os owner of the propany,will do rhe work ond the ' `."'.'. ,�......•• ....••'.�..•.... •_-.. ,'.-•.�. - struct�re s no�iNended or offered for sole (Section � � 7044,Bus ness and Professlons�Code). � - CONSTRUCTION LENDING�AGENCY - � I hereby nffirm�that ihere is�a mnstruclion lending oqency for � - �� � � ' � � - " � the performance of the work for which this permi�is issued (Sec 3097,Civ.C.). � !ender's Name - .. . .. . � � . . .� �� � . ., , ,, _...�w . ...._..>,. . ..w,.,....„.....,..w.. ..,,.,. , ,� . ....... . ... ...... .. .__.._.__......� __.., Lender's Address .. . . . . . . . . , _ ., .. .-.�.~.. . � .. _ _..... _,...._..,..._.............. ..._... � I cer�fy ihot I hpve read thls applic 1 on an�� ta+ ihot tFe� "' ""�""� - � •'"'•�•� above�niormation is correct.I ogree ro c mply w�F !I County � - - - � �' � ordinonces ond Srote laws reculc6ng Plumbing.ond hereby au'horize repre`sen!o!ives of Ihis County'o enler upoe �he ' abo4e-men�ioned orooerry for�=� r insoe<,�Yur���� SEE REVERSE FOR EXP:ANATORY LANGUAGE ... . .,;.� /% � .--_,.._...,......._...,.. . . 3� / noture of P tee G te - � � ._..�....._.._.,......�.�._.�....�.,.a..._., �_.�_. .__.�._ .�a�RaJ?is .,nie w=�[COR55iGNA7UR[ 'NSPEC70R'S�;OTES O'v+iiJER-f3UiLD�R�'rC._��R�"-.-1^,\I ... ..._.._ 'UNE25LA3WOfeC ��__ eeby fF '�5n� .emP f ��'.�eCc In%s 2(�UGH FLUM01\� �� , � � � L c_n.e ,7 for the to'o.ii�ry .ason (.isct nr 70�i 5. GAS.^�PING __—.--•;„-�..�''�. �.•...- - ..�.",�-�-�—�-...�:� a 8asiness and v�ofessiod.:Ccde;'.Any city or co�•r:ty w!,.ch __._.« .—..—_ ' .. . . ...... �• requires b�}�ormif.'o Lons�ru:f,alrer,lmprove,: r�!�s GAS VeNi � ���� �., - �n'� ' oa repair any s!rudure, crinr to i�s,issuante, alsu re� �,"OT WAIER NEA.7,-R �� ���i — �.'-A ruires}Fe applicont£or s�ch pe-mif 10 fiic o signed sfr,te� §�L lB�N,��%'�7R� I � - �" c rhar he rs Lc,._,e�._,nsed pursuor•ro the prov�s cns o�+h�. GP�— —� � -- ._ � �..f "Yor�s LrCense L Chnof: 9' mmenC�'i�,�•..ii �'Ui t7V�O.Np. IE� ,:__ 5 c9 on 700�Jj of Divi 'ci 1h Bus�.ss anJ Profss- ,µ-r—��,� � � o�s wdeJ or 16at'ne�- enpr Fe .f m and f�A bcs•s �_______,_,_ I _, � �� ' _ ` "' for tne alleyed ex,..07 cr, Any vio,r.iion r.i ,ec>on —''i�.�. ' -�7U3L5 b... Y PP P ! " p �4 P.7{ .,�-,r'r f � y an a umnf fo�a ermrl sun eds fh.,c pl! cent!o e crv�!penolty ef n�t mnre ihon 1 ve hundrad +,� . . .�� ��do�(ars!S500J. . N�US RAL � � , �I�cs owne `'Fe urepci y•v I,;o th���,ork urd i.�SiE AP�20�a� - • �� - --- � ,4,e siructure is nct�n�ended ar oFfered fcr=_ole. 1�r. ..».....�..�....�. -.v......-.....-. ♦ " _ ' � . �"•:-�� . . . �. ., � .� : (Sec.7044,Busirtess andProfessions Code� Yhe Contrer- . . . . _. . ._. _ .._.___. .,,..,....._. ' ���� � ' . �� � _ � ` ' _ � �or's Llcense iaw does nof opply to on owner ef property . ` � , � � who builds or imp:oves thereon, and who does sucn � � �' � ' � , �wo�k himself provided tha�such�mprovements are not - . ,_irrlended o{offered for safe.Jf,howev^r,t6e bvilding or . . _ , improvement is sold within one yeor of comp!etion.the ,,,,,�.,„owner-builder will Faveihe burden of proving il;ot he did . � � � not builo ar Improve!or fhe purpose o(sale,l . . � '., '} .. . . _ . .. _...S.y...... ..... ....t.!�_.�l.-.r.:.:.. . . I om exemp'under 5ec`� . .. . . 8 8 P.C.for'his reason - � ... . . ... 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