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HomeMy WebLinkAbout0788A (6) � WORKERS'-COMYENSATION DECLAKAT[ON '� oewssow � �he�,;bv affinn thut I have a Cettificate �t�ong�,� t�S�,f �Ea,�,xeo, APPLICATION FOR PLU,M6;1NG PERMIT insure,or a certificate of Wurkers'Compensation Insurance,or . � - � . u certified copy thereof(Sec.3800,Lab.G) � COUNTY OF LOS ANGELES ' BU1,4DING,AND SAFETY �..�Nolicy Nu. ComPany � � . . . � .. . .. . . .. . . - ��Certified copy is hereby furoished. FOR APPLICANT TO FILL IN(PFINT OA TYPE) BUILDING { • J��.R' y�' ❑ � NUMBER FIXTUREORITEM � FEE '4DDRESS /I�J' �/��./�I(06t^` L✓�� f�+U(.� Certified copy is filed with the caunty building inspection „ dep�rtment � � WATE�R CLOSET LOCA�ITY� �,� /' i � � �Date Applicant NEAREST ! �� BATHTUB CROSSST. '�'(/��� ' . CERTiFICATE OF EX�MYTION f�ROM WORKbRS' � � COMPENSATIUN INSURANCE SHOWER � OWNER ,�x��Cr� `��. y� �J . LAVATOiiV� MAIL �`r,� �✓,�� .(This section need nat be completed if the work involved AD�ftESS � C ,}� � by U�e permit is for one,hundced dotlars (5100)or less.) SINK C� - }� `'�7 & p..� , _ . .�!. . D CITV� � .:lU✓4��`r,1 TEL.NO. �-�J! g. � � rU I certify that in the perPurmnnce o[[he work for which[his DISHWASHER CONTPACTOR� � /�' .�permit is issued,I shatl nnt�.einpluy�anY person in xny manner � f d��fl � C�F1�$�� ;CL:� � an a»to eco e sub}ect to the ork rs'Con ensation Laws. , CLOTHES wASHER �� �ry �J �O.' ADDRESS Date Applicant��{� •C/</E::7(j �O.✓ �U� SWIMMING POOL RECEPTOFi � .�NOTICE T( APPLIC.4NT:If,after in�king this C,rtificate of CIFY ���. �� . TEL.NO. �� .Exemption, you shuuld become subjeM to� the -Wnrkery' � LAWNSPRINKLEfiSVSTEM STATE ll0. s� �Cwn➢ensatinn provisions of the Lahor Code,you must forth- LICENSE NO. � � CLASS � C� � . with qomplY with such provisions or�tliic permit shall he WATER HEATER � U OISTRICT NO. PROCFrSSE�SY � � i �,�deemed re okeJ. � GAS SYSTEM OUTLETS G�� j �.,,1 . / % �, � . � i IC;':NSL?D CO�TRACiORS DECI.ARA'fION OUTLETS OVER /' � L�K�CN = '".I hereby affirm[hat!um liCensed under provisions of Chapter 5 PER SYSTEM — . . P � � v�(commencing with Section 7000)of Division 3 uf the Rusi- . FINAL /�.� �� � VAUDATION �naes nnd P��festii�>ns Code,and my licen�e�s in Suit furce and � DATE F � effect. x1°'��J/���) ,L� FINAL �j � Licensc Number_+j�29y5'l2•��.Lic.�-Class <' BY �'^-�y�,� . �, . :Cuntractor���2�. .`G Date l�ja���� �� - 1,.: � � T am exempt from the licensing reyuirements as I am a � P�3n ChOCk fee .� �. licensed archi[ect or n registereA ptofessional engineer pLUM61NGPERMITISSUINGFEE� � � , �' . acting in my professional capacity (Scction 7051,Bus- • . iness and Professions Code). . . TOTAL FEE l� � . " � I,ic,or Reg.No. llate Plan check applicanx � � . �' � � � - rr+7o� n ` � `�� 110ME OWNLR-BUILDHR UIiCi_.ARATlOI� � Name ' �� �i3� t: ; ` -I hareby affirm Ihat I am exempl irom [he Contrector's ��'� Address � �e • o�w m�i . j��:.�i.icense Law for[he fnilnwino�v _� rcP�e_�.;.^„_.,,, .,,,. �.,�,��itY - Tel.Nm . '� t.� a(�.�L '�+ y _ 't .:' ness and Yrofessions Code): . � �- �� [,as owner of the pmperty,am exclusively contracting . r o�c u� b�r(;� S� ith licensed contcuctocs to construct tlie project � ` - ! �. (Section 7044,Businexs and Professions Code). , . }' '� ( '+.'.>(�,, t� ` ; << —8 1 .�. „ CON9TRUCTION LENDING AGtiNCY � { I . . � � �:�.�I hereby affirm that there is a<onstruction lending agency � � -fot [he performance oE [he work tbr wl�ich this permi[ is _ . . :-iscued(Sec.3097,Civ.C.). � ' `��l.endec's Name ____ � i ;, � �'Lender's Address � � -.�� � � � . I certify�tha[ I have read this application and state that the ��above information is cormct.[agree to cumFly with Atl Coun[Y SEF.RI?V�RSE FOR EXPLANA'CURY LANGiJAUG � � 'ordinances and Stute Ixws regulating Pluntbing, and herehy � � , �-�authori�ae representafives of[his County to zn[er upon the � . a6uv� �entioned property for inspection purVoses. -� � - � G� a �Gc.�i�cY�� .�'/��f���_ Signature uf Yermrtt Date: � �' ' . - . � � t - u�,° � z ;� � ;���I �'°c o� � �� � "� ''� I-� -I .W��cI��Z � ...D i i � s � . � D�;, ` I r ^';.� G�I m .m Z l l� � � I ,�, -� n�N z � _zi_ � N�� �.. �D � T'� `���' C D'O � «� x� I � z ' x z ' ��G:: . ' i �-�' . . .. . .. �.Q ' : .�0,�: I� m��,. :� i`�e � � ` D 'W � ai a a. I �� �m in'. Z�O � ''� - rV �'SI r` Iu�,�i 7i�� „ `� ° � � � :� �` `, z-, � f � I. ' � �� i ... � . �:'. ' . 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