Loading...
HomeMy WebLinkAbout0915A (4) � � � WORKERS'COMPENSAT[ONDECLARATION f8A68]p ' " ' "' '• " "v^^ -'�� -�� .. . . ... ..�... I hereby aff'irm that�I�fiave a certificate of consent to self �ceen�Z-ao, ��APPLICATI�O - � . LI.fM� f�f`�G����� "tiXt�� �insure,.or a certificate ot Workers'Compensation Insurance,or - ' ' � - 'a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGE LE�u BUI,LDING,QN�SAFETY.,, �. ... ..._'...... . ...... ... . .. ....... .. _.._.... :..�_.. ._.._......._.._ ���.. .. .. ..::.._._., . ..._. . , . ..�_.. ,,._... :,._ .. ....:::. . : ... _ Policy No- � ���� Cumpany . � i�� Cnr[ified copy is here6y furnished. FOR APPLICANT TO FILL IN(PRINT OH TYPE) BUILDING � -... .. . .. . . • . .�..� . ADDRESS BL�i CPZ. � � Certi�ed copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ' �lepartment. LOCALITY D �' .. ...._..._ . . , .., WATER CLOSET "Date Applicant NEAREST � ' '' BATH TUB CROSS ST. j � , CERTIFICATE�6FEXE\4PTTONFROMWORKERS' .. . COMPENSP.TlONTNSURANCE. , , . SHOWER OWNER ,� �- . ,:� . .� : . � . LAVATORV MAIL C I— (This��section need"not'lie completed if the ivozk�involved qooftesS J�. �'S 3C'�-S } by the permit is for one hun&ed Qollazs (5100) or less) SINK I S�fj`=Z/�& O - � �..� �'. � .- . �� - CITY TEL.NO. I certify thaY in the petfOrmance�of the work for which this � `% DISHWASHER CONTRACTORQ permit is issued.I shal]not emplol'any person in any manner a so as to be om subject to the Workerg�Coin eusation Laws.- CLOTHES WASHER i ADORESS J --,�! + � �Date Applicant �'� � ` ��'''-�`"'�Y� '. SWIMMING POOL RECEPTOR NOTIC�T APPLICANT:I,after making this Certificate of CITY v TEL.NO� 33 � Exempfion, you shouid become subjec[ to the \5%orkers' LAWNSPRINKLERSYSTEM � �Compensation provisions of�the La6or��Code,you must torth- STATE /� LIC. � "with comply with such provisions or this yermit shall be� WATER HEATER � LICENSE NO. ,$r/ CLASS deemed revoked. � s DISTRICT NO. PR CESSED BY GASSYSTEM OUTLETS I I �L� /�� - -' LICENSEDCONTRACTORSDECLARAT(O;� � OUTLETSOVER - � � LJ ��3 ,�T� I herebY afFirm thafT um�licensedbnder proviSions of Chapter 5 PER SYSTEM �9 (commencing with Section 7000)of Divisio�3 of[he Bus�- - F�NA� �)� VALIDATION "ness and Professions Code,and my license is in full force and ����' �'4' G�Cj� DATE CX .,�� �� "effect. �� /'�' /� FINAL � f, `�License Number Lic.Class L� � gy ��,Contractor 1����'Dxte / � . ���� I am exempt from the licensing requirements as I am a Plan check fee IicenSed architect or a tegistered professional engineer pLUMBING PERMIT ISSVING FEE$ � � acting in my professional capacity (Section 7051, Bus- �.�v iness and Professions Code). � TOTAL FEE �� Lic.or Ae'g.No. Date� � � � Plan check applicant HOME OR'NER-BUILDF,R DECLARATION - Name . � ' �� Addrass ...U C i�5� I hereby affirm tha[�I arri�ezempt from�the �Contractor's License Law Tor the iollowing reason (Section�7031.5.Busi- City Tel.No. fi�:s a, G s o� ness and Professions Code): � I,as owner of the property,am exclusively contracting - -� � - + ° �� � ����Q with licensed contractors to construct the project _. (Section 7044,Business arid Professions Code). � ° r� 6.:;�;� CONSTRIICTION LENDING-AGF,NCY � � � I L G j—� . .. .. . ........:_ _,._.., ..,, ......, ..- -... . ... .... ... . . . . .. . . I hereby affirm thaf there is a construction�Iending agency �- � �� - - - � � � � foc the performance of the w'ork�for which this permif is �- � � � -- ���� �� �� -� � - � ' � � issued(Sec.3097.Civ.C.).� � - �� Lender's Name -Lender's Address � - ���� � - - � � . . . . �� . � .. . .. _" ,. . :.. . .,,".. `{_� ,. -, : �, . , " . - . . I certify[hat [have read this aDClication and state tfiat the - � � � � - � - - �� . ...., ... .... . .. . .. .. . . . . . . . . a6ove iriformaLion is correcf.Y agree to comply ivifh all Coun[y . ..gEE REVERSE FOR EXPLANATORY L.4NGtiAGE 'nrdinances and State le�vs�regulatin�• Plumbing, and hereby � authorize representafives of this County to enter upon the � above-mentione ro L�ty of iyspection purposes. X a.,�� � ���_.3�i' Slgnxl�re�of Permittee Date . . , . `..y...;,. , .�_�-. . ..-- -- �_._.-_—_�___�____--.._.------ d. -- . - RPPROVALS ��CATE INSPE�OFSSIGPiATL'RE .��,_ INSPECTCR'S NOYES � � �V�IIVER-T,�iU1L.DEFd DEC'L/��iATIC)N U�iDES,SLAB b^/ORK - � ^ � — ' . .-. .'."'� . .. .. . � � �� � I lzereb}�af?irm lhat t xm exemnE fcom[he Con4xactor'S P.O,UGH FLJPA61�— — GaS PIPING l (/ �-> �n� n��� S_a�ensc Law for Lhe 4oSlnwing ceascn(Sec?ior 7031.5, �Il�rJ_/ LlXp�-�'� � -- _ Fusiness anri Prafessicrss CYidel: �7nY c'itY or cour,ty, ._....._. .. . ._ �7�Y. , GA V-N; �� .. , _� -' Nh� requires a penr,(r ru ca:strucP, arter, rmprove, _ _ .`.- . :. , . ., : HOTWATERHEATER . , — _, _,_ �.T��. �E�'.1!FS�:, OYYCpRY.an} SfTuefu.P �hDY tn d.s ,ss��ce, ' ca PLIMBfuG�IXTURES � . _ . �� . . . . � �. �. �tm Ie'eQ��tQw.:e�Sf tkal'jftC'`iS I1C�PITE�ALlI+"UQ71YO(O'tMe ---1— r�!.--. ._ ..-'--- —__.-------.�._ _.�,—� siyne A GAS TEST %�/�/t31 . -.-�; pror�iaiuna of the Cor.tractnr'a :icense i.aw(Chapter 9 1..---`----�---------- uriu�7v cn.n�oTiFieo � --� --- . . (remme+�c;r.g wi:� Sec•!ion 7r00J ef Diviseo�a 3 n;:he ._ . . . . .. . . -- __ , Buciness ard Profess;ons CoCe) cr d�¢t he is exempt . , _ .. Sherefrwn cad ti�e bas#s fo;rha aileged ezerrptiort.,9ny. FINA�_ S;�,f,p�y p� 6�'g�.p,:� , � �. . oioiaaionofS:cY�rr7C37.561'�n5'ffPrlicantforape:mii . . , ... ... :� � , , � _ _ su8jee;s alte appiic�nt to a rgY:?�:e,raiiy of r.ot mnre rha.a ��vousrai.a� � � � - � jivehur.dreddau¢rs/$S00/.: 'NASTE APFROVAL �� � — , C I.as OWOCC U�ihe property�+�it do tlbe work,ar.d � the structure ps no4 intended or offesed:ox sale. .... . .- - . ._ . .; . . .. . � . . � .. ..,._ .. . . . - . � ... !Sec. 7L-'4a, Businesa�end rrofessions �odA: The Con� . . ., . . .. . . .. . .. � .. . . .. . . � rracmr's licer.se daw�does r.or a�pty to an oK�ner af . . � �-�� �. ., .... . �. ..:.._. ..... ......... .. .. .•.. . _ . - ro e who _ . — !�„p�ty�� buil�s nr improves ihereor,ar�d wh�does � ' - � � -� _ • � , - � � � � � - � � � , � such work erimse:f �ros�ided that such. im.provenients �. . .. -�::� ���-� ... . ,.. _ ,_._... .....; . ...: : ' - are r.ot intend�d or ofjered fo�sa7e. I�� however, rhe . . .-- " � .. ' .' �� � . � � . . . � huilding or irvcprcvement !d SDZCI w%t.kir� nne year of , � " _�. cn,mplet:on. the own?r-hr<;ider ,v:!% f�ee !irn 5urden . , „ ...: . . ,:: ..- --�— . .. �. .. .. .... . _ ._... .. _ .� � - . . � . . . of�roving thaS h2 did no? buiid or irnprove�for rhe . . ' � ,�_. . � . . . . purposeofsele./ . . . . .. ._ . ._ ._ .... . . . ., , . . . f 2ill 2Xf:Y:Qt llll(IBT$2C...��_.—_�,�_._, �i&P:�.F�tr this:easoi�.,___._ _._ .. . —_ Date . _ Owner . � IMSPECTOR'S NOTES ... . . • . . .�. . .�� � .