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HomeMy WebLinkAbout1381A (7) . - -^:':: ,,: ,�3-�..: ..�..: �,� :._ , - .,;.-„. .�..�... ..:......:.:. . _ . _ . . _..y�..a" . ...� . . .Ya - .. _ .. . �. ._.�_, � ' ;. . .. ... -..:: _:. .�� . , . � . _ . - � .�.r, . . .. .� � ,.,..., . .�. '" _�... _ . " , ... _.. .. WORKERS'�COMPENSATION DECLARATION t'� �� � � i.h�.br,aif'rn thot I ha e a cetifcate of�consent to�self 76A667A ���" ��PLfC�i��d�6 FOR-�'�LUNi��I1VG PERMIT . . . �� ..� .. �nsure,or6�cer*drea�e of Workers Comp_nsction Insurance. CE 897�REV.8/88) � - - `- � �'� ' �� ' � „ or�o cern � copy thereaf(Sec'3800,Lab.C.J - .w.. ; .; - COUNTY OF LOS ANGELES DEPT. QF, PUBLIC_WORKS, ,., . P❑ol<y Na. Company . . _ _-. _ . _ _„_..,a. ,..... . Cen tied copy is hereby furnlshed : ❑ , �-- � - � - � .-- �- �� -- -� FOR APPLICANT 70 FIIL IN(�RINT OR 7Y7E) aU1LDING Cer'�fied mpy is filed with•he counry�6uflding inspec- ADDRESS �{3�ia (.,l� �on depa t e t. NUMBER FIMURE OR ITEM [�.?. FEE �OCALITY /� � . . .. WATERCLOSET 1JIP�'�a�n� � _ Date � ��� `Applc nr���~ �' �' :: . � . � NEAREST A CERTIFICA E OF EXEMPTION PROM WCRKERS SATH TUB CRO55 ST. U � . `��� COiNPENSATION��lNSURANCE' � � � OWNER sHov,�R l�l. � (This section nea�not be compleled f 1he work.involved by MA�� .. Tha permit is for one hundred do4lars(;100)or less,) LAVATORY ADDRESS '� rn.fC.- I cer'ify�hat�i the performance of ihe�work for which ihis , permii�s issued,I sholl not employ any person in any manner SINK C�TY 7E1.NO�� -- sa ds ra become subjetl to the Workeri Compensation L ws. DISHWASHER ,� CONTRACTOR ������,�1C) a�j . Date.�E�Applitanf � 9, CIOTHES WASHE2 ADDRE55 1� , NOTIC T APPLICANT� If, ofter moking ihis niii ote of L�to t'i � � � � . Exemp!ion, you Should be<ome subiect to 9 e or s' SWIMMING700LRECcPTOR Compensation provisions of the Labor Code,you must forth- ❑7Y j TEL NO. � �„�� IAWN SPRINKlER5Y5iEM � `itF comply with such provisions or this permit sholl be STA7E sy IIC. , - �deemeci revoked. WA7ER HFATER L!CENSE NO. {� CLA55 ��7�Z.� • " � �LICENSED'�CONTRAC70R5 DECLAR.4T16N' ��� � oiSYaicr No. �- � PRocE55Eo Bv ` I hereby af�irm thot�I om licensed undar provisions of Chapter 9 GAS SVS7EM f OUTlETS � � �,(commenung wi�h Section 700C)of Division 3 of the Business OUTLETSOVER � ond Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAI VALIDATION � License Num6er�>5,157� ,�Lic.Class�-� � �w"� n'9c^' DATE �_ G _G�� (,r (���q_,,+� ryO ,! FINAL � � rontraclor�"'�CX���...�"�14s�°'.9ate 7--I`�i'Z SY �! � �� I r� � _, .... i i G`. � � ❑ I om exempt under Sec. y� . . . . . . • . '}Y e . � e � � s av.c fo�rh�s reoso' Plan check fee � - Dare: i o a �i E.�J^. . � � � PIUMBING PERMIT ISSUING FEE 5 S�gnatore ' � . . . .. . . `� •S G �s -: :• � F.`,,,.,_ . . . . . TOTAL FEE ." . � ..... , .��..� ... .. � Plan check appficanf 2„ _�� '�� �^�,l'�'���s � . SINGLE FAMILY , HOME OWNEI7-BUILDER DECLARA?ION Name I hereby affirm that 1 am exempi from ihe Cantiacior's ticense Address ' . Law for the foliowing reason(Seation 7031.5, Bosiness and � � �' � �� � Professions Code): City ��,�' � Tel.No. �„ tl ❑ i,as owner of ihe praperty,will do the work ond the � " � strudure is noi iniended or offered for sale �Sec�ion ' . 7044,Business and Professions Code). CONSTRUC7ION tENDING AGENCY � � ' � ' - '" '" "- ��"�' -" '� "-��- - � -� - �� I hereby afiirm fhat there is a tonstruction lending dgenty for � � � . �he performance of the work for which ihis permit ia issued (Sec 3097,Civ.C.).� � 4 � Lender's Npme ��.,.�;_.__ , � � Lender's Address / � I cenify ihaf�I haJe read rhis�applkotion and sta�e thot the � � - above informaliqn is correct.I ogree to Comply with pll County � ordinonces and 5}ate laws regalating?lumbing,and Mereby authorize represenrotives of this Coun:y fo enter upon the ohoye-mentioned propeny f nspecuon purposea. SEE REYERSE FOR EXPLANATQRV IANGUAGE �� _ � ���__._ Signature of Permitt pate ; , '_'_.�....__.._.....�_-----.-,-�...-.«,.......�..,...,d....w.:..............�.,,...r. .::...._�....«.�....,._��................,.,....,.,..:. ., ...._..____:.__,.n,�.,,__,,,__—_--.__,e__.. .._ . -. ,_,,..�,,. _._-.__ ......__ _ �_.. ,��._:,..�, .�::,-_,;,,�.... ..:-.:.. ,..��,:.M:,, .�_-- �� . � f i�<K�r'`"'Sm�� �,.--�1�'-;� .. . :'�- &°�'�. �.�. .. . .. .�J:_ .. . .;;� . . -- . . . .. ..... . ... . � � - �. � . .�:.:.�i:�� _ .. . -.. � _ � . . � . !tJSpE 70R S NGi£5 :e�� • .� . . -' .QtNN R B�i'DFff�icr'F;�A, I i ' : APpQUVA 5 JAiF �SPE TOR S SIG�IA7 JRF i ,.__ _ �_� 7 � - .. -+-py�- , ;..�, $ ,y.. . . . VNJER SIAB 4NORK � 1� ' � . 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