HomeMy WebLinkAbout0932A (9) WORKERS'COMPENSATION DECIARATION � i- APPLICATION FOR PLUMBING PERMIT ��
I hercby affirm tha�I have a ceniSica�e of consent to self�, 76qyy7A "
insu�e,w a certificafe of Workers'Compensation IrrBUM�c9,. �'E 817(REV.10/81) �
or�a cer�ified copy thereof(Sx.3800,iab.c.) � COUNTY OF LOS ANGELE BUILDING AND SAFETY
.PolicyN��_a3 Compony 4i4T� FlIN� ' � - .
LjCenified copy is hereby furnishad.
� FOR APPIICANT TO FILL IN�RtINT OR TYPEJ qp�� ZO 'H, �V .
CaAified copy is filCd with the counly buildinq inSpBt-
� tion departihent. , - NUMBER HXTURE OR I1FM � FEE �«�n n
��9— �►t1-L���f�j'�Il� WATERC105ET �LSM�L
Dpfa Appli4ant - .:C��S�. O .
CERTtFICATF OF EXEMPTION FROM WORKERS' BATH Ne
COMPENSATION7NSURANCE SHOWER �R !-�E 7 �
(Thts saeHen need ne►bs eompAlad fF t�a work imoiv�d br � '
the parmN i�}or on�hundnd dollon{S100)or lets.) a uva70Rv , � AppRE55 � :
I cer�ify�ha1 i�rhe parformanea of the worlc fo.which ehb . � � -
� permil is inuad,I ahall rrol emplpyany perspn in ony mannn 51NK ' CITY � 7E1.NO. .
' m m�o beeome subjec�ro rAe Workri Gompemarivn Lcws. p�W� �
CONTRAC70N �� �
Oate � appticant qA7HE5wqSHEa - ^- .
NOtICE TO APPlIG4NT: If, aker rtaking thi�Certiiicate of A�� ��/7 S �� Ko .
Exampfion, you shwld�becoma s�biecl 10 the Worken' SWIMMING POOL RECEPNR
Gompe�+w�ion provisicro af rhe I,a6or Loda,you musl foAh- �qWN SpRINKIFR SY57FM CfTY '�T ���7/!��9L4-? �i
with comply with such prorisipn�pr Ihia permil shall be STAiE LK.
deemed rawkad. WATER HEA7ER � u���� 7 S2(. GVSS �'�
uc�NSED C9rtTRAS�DR4 Q�+RAnQN oisreicr No. raocFss�o er
J hereby affkm�hoi 1 am licemed undx proriziomof�a�ter 9 �S�T�'' �7� Q ta �
IcommerKing with S�fan 7IXq1 oF Pf►ision 3 pf!ha 8usi�+eu puTlE750VER . . y �
+eu d
and Professions Coda,and my lite�.s9 ia in fyll forcean�effen. 3 PER fiwu j VAUDATION � � �
397szlo �. B-/ - p nn� �Icel� � ,
License Number �c.tlase .
Contractor �'L 13HL"LOiNG Oata /—q►8g. t ' . � .,gyA c CsJ>� � • . V ;
� 1 am exempl vnder$ec.' . . � y •
Z �
B.&P.C.for ihis reoson Plan chetk fee �
Ddte: pLUMBING PERMIT 1$$UING fEE i !� � �
� Sigeahxe ` v .
�o,A�� y
� � Plan check applimnt ,
SING�E FAMILY �
� HOME OWNER•BUILDER OKIARAAON Name �
I hereby aff+rm tha�I am exempr from the Contrac�w's lironsa � A�5 . ��9�2 a �
Law fm�he foL'uwtny�euaon�SxHon 703i.5.Businau ond � - .
Profassions Coda: . #• • • •�•5 i
1 CiN Tel.No.
❑ I,as owner of the praperry,will do the work and the �� • � 2 4.Jr�
shucrure is no�inlended or offered fw wle�Setrion �
7044,Businns and Professione Code). , �� • � C tl,Jr Q c=.�
CONSiRUCT10N IENDING AGENCV . !
I hereby affirm�hat�here is a comhuc�ion lending egency for O I�O 9�8�4
tha pedormunce of the wwk for which this permif is issved .
(Sec.3097,Civ.C.). �
Lender's Name � �
Lender a Address � � �
I certify thol I heue read this applicalion and sfale Ihaf�he . , . . 1
a6ore Informotion is ca�ect.I agree 10 comply with all Counly
ordinances and S�ate lows regulalinq Plumbing,and hereby . '
aurhori:e representotives f rhis Caunry to enter upon the � �
obove- r�o prope� �nspxtion pu�poses. SEE REVERSE FOR EXPLANATORY IANGUAGE
/"g"$� . i'
`jgmture af fer �nee Da�e . � .
t
� � $ i
� � O N `�' G� A
G
' � N 7i � � "p 4 N y0
� L� ' 9 � M � q i � C m A
.. �N r O � T y � � 9
, y�q � G � � � N
-o� '� m N
�
� , O o �,
q
� O
, } ^ �
�
- O
i. � ; ' �� �
�t - . T `�
\ � � • • _ •1 � •
� � . 7-
O �
•� � A
` N m
� Z
,` p
� �, :__
� .
1
)
,�\
' N
�
1 •- 7�
N
�
..i
. m
N
\
� � _ .
�,
�
\ .
,, �
�\ �� , .. ' � �' '- . .
\ ._ . _. .
\ W � S
a °� N �c, o
.n
�a � � � n C W �O m o�
.`\ ¢^ O p O y + �_N� � N �
O fl � N `^ r O
' £ f o �m a� �,� c�� �o q ° �f � �
� y S n ^ O Jp O Q'II 0.
• y�� W �� f�l GON p•�G �4 8v� tse� -'C O � ����. m
� a, p' n c' .2:' � n m a r �:ro. �3.0, S .'�
� � amO. m ?='.o �.� o $^-o ,c, ° �� ^ ms� �
• Q ¢� � . c m o.3 d w m " �•"c � N n �c o � ° -- G
� a � x ��� ° �.o q'�N �v'9 n o °�m N � o � o° O
� � C� ' o ° n-...°. f m�°..� ��n o N �$.� �' '�^.,� �3 `n
` � o -�a� „�o��,�0 3 a.N � o ��3v '" � £� ^�D �°n.� � a
? r.o c. a� n A - � w^� so . mw 3 m
, N a- �c°'�'a.< �c.ao °� �� �oa� o��,� �
c� m �� � °.�a'e o o � v �3° m � o '^ �a
,' ¢ . N ° 7T ��T� � a $ "' � � mmo — N , _ �� r�
, � > � „`�a �� -"� `�� �n-� �3<���m cyco � no 2
'.,` . . . ' c 0.m S 3,� � N ^�.� N � �� O � O .�.. � .
'O
" _° ,�ie °�3.Q � o°" uc°3N3°`—N•^ mc3 ? -
` � oo -o � oao°' � m ° o �o � � ° o-?
m ' o �- q ° ...N� � � � o � �= � �o
\ °.o c"a m � � o � � o ° c-� � °-�o ��.'o
�. ' "o n' T� :r o '^T �o � .
�n.< O 7� p 3� f 3 m t!�N 'D t� O � �n n.�tn �r
��,` Q53 s� o�c� °^r �-°�^.o Q� o c� q ? s �.
, �v
. � . ' � ,��,q C '^ �p Q n. N .n T
�. O N "O O .
' � ' � 0- `O .D. O Gr _. > w
s> > 61 � m o a. °" �
� - m � ,. � ^•
'� �So o T
,\ - °'� ' ' �„�
1
\
\ .