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HomeMy WebLinkAbout1542A � ' WORKCRS'COMPENSA'CION DF.CLARATION �� � �swssow . � ,. �. . � h���ny ��ffirm �h�� I have ��trt;�;���e �f consent to se�f �E a,��=-ao, A P P L I C A T10 N FO R P L U M B I N G :.PE R M I T � insure,or a certificate uf Workers'Compensation Insur,ance,or � . � �� � � - �-' . a certified copy thereof(Sec.380Q La6.G) � � � � ' �� � ��� COUNTY OF LOS ANGELES BUI LDfNG AND SAFETY Policy N �'�i�� ComPany . . . . �Certified copy ie heteby fu[aished. f''v� Iqr'3- FOR APPLiCANT TO FILL IN(PHINT ORTVPE) BUILDING �� ``� ��;� r� � ADDRESS �ia� L .. Certif�ed copy is fited with the county building inspection �� NUMBER FIXTURE OR I7EM � FEE llat�depar men. t� ��� � WqTER CLOSET G LOCAU7V r . .ApPlicant� �� Ub1I/h—. � / � NEAREST � . BATH TUB CROSS ST. (t..� ' : 1 C�RTIFiCATE OF EXiSMNTION 7'ROM WOIiKERS' /�p�/� � COMYCNSAT70N INSURANCE. SHOWER OW�fER ' � M A I L,—"'��` ,:(This SectlOn need uot he completed iP the Work tRVolved � LAVATORY � �� ADDRESS — —�LD_eS�� � ;,.' by [he permit.is for one hundced dollars ($100)or less.) SINK p r� r� - . . . p L_5� GTY�,'," �� ., .. �_. TEL.NO. i,�,�� I cer�ify ihat in the perfm�m.�nce of the x�ork for which[��i.s DISHWASHEF2 CONT�R AT OR����JKs I��' �� permit is issued,[sh�ll not employ any person in any manncr w as to beCome suUject io the Woskecs'(:ompensahon Laws. CLOTHES WASHER ��� ADDRESS �+�Q � � �'��- � �1Jate APplicant � � ���_�. SWIMMING POOL RECEPTOR NOTICR CO APl'I.ICANT:iF,after making thts Certificate of CIT . � � T � .�f` �j .�.�xemption, yuu s7iould become subject tu tlie Workers' LAWNSPRINKLERSYSTEM �% � �-�Com ens�iwn rovisions of the Labor Code,you must forth- STATE ��QL.:y{ U0. � y t�,2� � p ���3 LfCENSE NOp4)r [ f� J� . with comply with such prbvisions or [his permit 5huli be � WATER HEATER l.4 CLASS ��� � '.��dcemed revoked. � GAS SYSTEM°'7 OUTLETS O^` P�STRICT NO. 7R0 ESSED BY �A-- LICENSF:U CONTRACTORS DECI,ARA'l1UN V + � �� � OUTLETS OVER �1 n\ `� ��� �, . . 1 hereby a4firm that 1 am licensed under provisions of Chuptcr 6 PER SYSTEM y'K.� � v i �.. � 9 (rommencing wiih Section 7000)of[7ivision 3 uf the pusi- �. s� �t (�� FiNAL ���� j�� VALIDATION . � �ness and Professions'Code,and my license is in Suil forcc and l :i��Y.�.SV DATE 1 ' � effect. � � /t j� PINAL�. r ... ' Li�ense Numb�� Lic-Class_! '"�p.. — gy {��.`�.�'�qµJ � ( �"�t'_�� �Contructor��%Jf_y=— Date . . , . ,.� (um exempt erom the Iicensing requicements as 1 nm a � Plan cheCk fee � , . licensed architect or .� registeied professional engi.peer pLUMBING PERMIT ISSUING FEE$ � � - - acting irt my professional cupacitY'(Section 7051,Bus- � iness and 1?ofessions Code). � ' � . TOTAL FEE S� . . , :��I..ic.ot Reg.No._ llate . Plan check applicant � - � HOMB OWNhIt-HUILDF,12 DL;CLARA7'ION Nsme � �.-I tiereby affitm that I am exempt from the Contcactot's ��� pdtlress� _ ' . .LiCenae Law fur the foll��w�..g . sen !Sec!i.^.r. 7^3:5, 3u.;: �.Lty Tel.No. 'y �i { �ne>s anJ Professim�s Code): - �� �J/.�,Q{� ..,I I;�� I,es owner nf the property,Am exclu5ively contractirtg �� ��� � ' � �5 I • with licensed contraMurs to construc[ the projeCt , '! � f (Sectton 7044,.IIusiuess and Pcofessions Code). ^� ' f o •98,5Q :: F, CONS'1'RUCTION LL•'NDING AGGNCY � (�� °�° e�J$„S,O= .:�-i Itereby afTirm tha[there is a construction I�nJing agcrtcy . . y,. . . =.:;fot the performenec of the work for which tliis perini[ ia � �,z,� t '`8? �issued(Sec.30v7,Civ.C.). ' � . �'Ixnder's Name _ � ~ �i ' . �_'`Lender's Addrzss � ���:I certify that I have read this applicatiun and stflte tliat the - ._. ��above information is correct.I agr�e to cumply with all County � SEH RF,V IiRSE FpR LXYLANATOKY I.ANCiUAGF. :,��ordinnnces ;ind State l�ws regul.rting P)umbing, and herebY , - '''�.uuthurize repr��cn[atives of this Connty to�enter upon the . • dabove-mentioned pr perty jbr inspectio9.yly_r oses. � - .. . � �. � �gnature of Peuuittee Uat � % , 't � , _..._. s- „ �c "c��� x I ii ��i�c�:".�. Dz z � � D C �;D D IO zI O I -I co I v, i ! �C D ` ��� 'W;S` �.'-c � p D q � � _. . m�� r -G��IZ � m��i 2 � v � � � D7a � I !•i,• � 'n .�; m�Z ,-i�:� 17 �� �� � � 77�i�,'�`. � ���� O i � � f� . Or- ` k O I I� D�-,- W �II D .� "° � � a , . D. � -n m m t':..` I z �n i. �� r-a..:. iC3 I.o� :m �' i� � " 3 — �..I � , - m� �.' �f � \�� � � C7 ' r ! I `',..� �.. ,�, 'D O �s� >' � I � -I 'b -- �y� I I I r.IK �+� y I` i. i I 0 l �I I i.,- N � � .' ^� � . 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