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HomeMy WebLinkAbout1024A (5) - WORKE.RS'COK�fPEN�ATiON DECtARAT161�T .... �swes>t .:.�... �'..:.' . � ��:� � ��.. `:. .' �-� .� . ' r , � .. � A F'P T I01�1 F�. 4 .� ...�}.�,�'-.._:.. .. __ __ �nsure or a Cert �cate ot , ._., .,. . ... .� �������ry��� Y P lmeNoaf`irm Yhat I Wo�kerseCofmpelsat on insurancesor � cE 61�f 2 80 � �COUNTY Ct� � a ce t f ed opy thefeof(Sec 3800 [:ab C) F LOS..NGELES BUILDING AND SAFETY LI A � . _ .____ .. - Y � CompanY . . - . . ... -. � �� , , . . �- .. .. .. .. :.�:.�. ..:.. ... . .. . .. �... ..- ,..'.: �. ._. . ❑ Cert�fiad copy is hereby Purnishem . POR APPLICANT�TO FILL IN(PRINT�OR�TVPE) BUfLO1NG �����.. � - ! - � °.• � = .: , . :;°� � '{.; . ADDRESS �+f.. .� .,�;J Certified copy is filed with the county building insptCtion NUMBER FIJCTURE OR ITEM • FEE ,... �lepartmen4 ' WATERCLOSET . ' . LOCALITV �'J/;i ..... �;.,.., J�.,n,.;,,� D'ate ` Qpplicant �� '.` '. ...... . � � :. . PIEttiREST � �� � � BATHTUB CROSSST /'��'j' � � CERTIFICATE OF EXEVYpTTYSiV 1'RDM WORKERS' � � . . �+ ��-' � �� COhTPENSATTON"INSliRfiNCE:.�,' "� �� �SHOWER OWNER t ;�_�..y , tg; , ,��.:. f � n= - .•�� . .. . . . .. .- . . �.,•',^.... .�. (This section�need ao[��be comp7e�ed if tl�e wo�k in6olveQ��" �avA70Rv� : . . . MAiL �� z , i ;,� aooaess � . .:`v by the permit is for one han&ed dollazg (^5106)ox lesa.)- siNK ,.,.,.��..�, � �.'. �. .., �.. . , „ . .. :- ;- CITY .:_.,r.. �F.':�, TEL.WO .. ...`:'; . I�cert f ihaf�tn tiie performance�of the'work��'or�vhich this ❑ISHWP:SHER � �� �. perm t�s"ssued I sfialt�nbt etnyloY�any person in any maMeT� I � CONTBACTOR �� .� j x so as to become�ubject to[he FVorkers L`ompensation L$ws.� CLOTHES WASHER� � ; qD�RESS '�;; -�l� ,r�,' j,� f ! � " � Date � APVlican[ � ' �- � � . SWIMMING POOL RECEPTOR - � � - � Q NOTICE TO�AP'YLIC:INT Yf,'st'ter�mak�ng fhs`Ce 2ificate of ' CITY TE�:�NO�, ' �` Exemptlon you should tiecome .su6]ect to the 4�orTcerS'�� �AWN SPRINKLER SYSTEM I STATE � ��r� +� �Z Compenszuon proLis.or.s of the Labor Code,you must fiirih=-�`� � . .,� .s�� �IC:-� � ' .} s , �'� : .� ��ivith com ly �vith such ' � ' WATER HEATER � �ICENSE NO. " CLASS " " .. P pro eR�oas-or this permrt sha:L be � deemed revotced. � f� GAS SYSTEM �`�OUTLETS � ' �j ,y,; DISTRICT NO. - - PROCESSEo gY �: LICElY5E13C07VTRAC OkS�DECLARATIbN ��� -.�� --• OUTLETS�OVER � - � � ,+� " . . .. ., .. :;- t:..: [he bv aSfinii fhat T am��ficensed urider provisiorts of Chapter� �- `� 5 PER SYSTEM - � - �9(commencing with Section 7000)of D'ev�sion�3.oF the Bvai- � .,;.� - . ; ^'- � FINAL � :n�e'ss and"Profess:ons Code.and my liceuse is in full force and�� ' ?'"` �� - E., ' .�C "�.'1 -� �� "`eTrect ' onre VALIDATION ;. . . `.1,!s T i �.', .. � .:'.., ' .... - FI.NAL License Number_�_ Lic.Class ` .... � _ � �.. .� � gV � Cnntr�ctor�� �"' Date �^'`� � � -❑ � . �::: � .��.? � .�.:� . . .. �.. . � � . I am exempt from�tne liceasing requirements as I am 2 Plan check fee �•r iicensed archtte t o.r;a.registered professio�a] engineer pCUMEING PERMIT ISSUING FEE.$. � ' ,.� acting'in my proYesseonal capacity (Section 7051,'$u§-���� % ... "� .... .__.._: . ...... '�� iness and P ofassions�Code}. : TOTAL FEE�� - '��' . - . . . .... � . ' ...,..: �Lir,or Reg.No. � � � � Date�� � � Plan cpeck�spplicant � � � � � � HOG:E044NER-BUILDER`LSECLARPTTtlN ��- � Name . _ ,. . _. . � � :�,.:. ��..:.. �� .. I herebY affi�m that�1 um exempf from the��onftsctor"s� Adtlress License Law for the foJlowing reason (Seciion.7631 S,�Busi- City Tel.No. ness and ProFessioas Code)�i �� " ��� � � � � r _� �„F Q� - � . ... .... . :..... ...:.. . . . . . _. ... . ...-.- �,. .. . .. . . .. . ..... . _ ,. ... � I as u.wner of the property,am exdusively contracting �� - ��� wrth iicensed contractors to cpnstrucY the projeci ���� "-� �'��- ""'��' " ""��- ` � � --��-� ' �����-- ---- �-�--�ro ':.(Sectiors�7044,Busirtess and Professions�Cbde). � �� -""�� � � � � �N +r����'� �' . ,... . .. .. ... . . :� �.. .. , , .. .. . .... ��. :.�. . .� ., .'.._ .;. _ ,,... . ,: �. .�`{.t C.�:i�. ��� CONSTRUCTI6N LEN➢INC AGFNCY �- ' ' '�-��� ' - - �- --��`� � • �� ��� . .. ' . ._ . . .. : .�.. .: .. ..,. . .�;, t r :;,� I hereby affirm'that tIlere is a construct�on lending agency ��� � �� � " ,.y ', for the performance of-fh2 work For which this � � - � �"� � � � � � �- � � � �- .. - . .� , permit is � - - � ' -is5uea(Se�30�97 Civ�C:).._. . .....__.. ..._... .. _....... . ... .... ....__.. ..._. . ..... _... ...... ....._ ....... .._ ..._ ,..._._. . ....._ .��. ;.,.�, . Lender's Na.me �.` .. .. .. . . . . .. . .. .. . .. . � � : , �` . _ .: .�'. . ..'.,. :.�.. .). . ., . �. . .. :'., .. �.. �ender's.4ddress - . . . . . ... . . . . . � . ...- .. � .. . �. • ... ._. . � _ . .. .�. .., .. .. . . . .-. . ._. ._.. :.. ..,. ....... :�.. , , - . ... , '..� .... .' . .. . ..�. ....�:.� „ .,. �., . . .. . I certify that 1 ha e read tnis application and s[ate that the � �� �� � � �-� �� � � ' - ��� � � ��� �� � � above mformation is coaect I agree to tomPlY w�ffi aIt Count�" ...,.."�' ............. .....`.. . -:�.^`".. ."' . ,. .�---�.. .-.. ...-.....•- .. ...--....-. - -. .. .. .....,..... ..,_. .-..,.._ rM.,.... .,�. .,. :... ordinances, and State t'aws,regulat'ing Plumb�ng;�`and 6ereby '-� � SEL RHVERSF['OR EXPLANATORY tiANGUAGE � -� � - authorize�representatives-of this County tb enter upon the � - � ���� ' - ��" � `�� � ���-�-� � �-� -- �� - � -- -��- �� �- ��� - �-� -•�� � above-mentioned p.roperty for inspec4ion purpose5. �� ��� � � �� � - ' � � �� � � � - � � � ' - �=> ,. . ,,;;,,.. ,... ,..��. , :. . � S�gnatureofPermrttee�... :�i Date ., ... ,.., . . � . ......,_ , . . � ..::.�. . .': . . . .. ... . .: . :. !.:, �j� .. .� ' .:'; �`.:� , . .... ,. 1<<-e _�. ;, � ' ' . . . . . : �': __ . . ,... . .,•,.-n ,..,.., ...... . . . . . . . .. .. .- _...,..,��� �..�_- ���..�..�,.....�.._.._.,__��—.---- _ �....-, � �. .-._-_-c.,..�.--� - �,. ..� �. �--�,.�.�. � � :;.� - , .,-, i� . . ,. � . . ...,: .. , , a ; .. , u �.� .-. . .:". ,e_ '� z: r•F.,t ' ' � � ..� �.� ' �.:. _ . . . . .. . . �..k.i, ...,.. ...�..t. . .. . 1.,d:! . . . � ... . ..., .. � y.....:,.... . .�. ,,.... .,.,.:.�.b....�. �.......,.. i.,,,- ..'.;r .�,. � . 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