HomeMy WebLinkAbout1121A � WOR�ERS'COMPFNSATION�DECI.AHAIION � � ��� � „ppLICATION FOR PLUMBING�PERMIT� , � � � �`�
I herehy affinn thn! I hmn n cer�ilica�e of consent�o self �7n�6G7n� . , � , � L1
inw�e,o��a certilimte of Wnrkr.rs'Cmnpe�nsotion Insur�nce. .CF.tlli(RfV.lU/61} ... �
o�a certifeed ropy thereel(Sec.3800,�nb.C.? COUNTY OF LO$ANGEl�S BUILDING AND SAFETY
Policy No._ _..._Con�pany. ... — . . , .
�J Certified copy is hereby furnishcd. ^�--- y'�
BU����N� -� 17 � v.0
O FON APiLICANT TO FILL IN(PRiNi OR TYPE) "'�, �/ �y$�.a
.Cerlified copy�s filr,d wilh the counly building inspec� ADDRF55 ',}�.� M' /�+�'� �
'tion deparfinen!. M1U�ABt�R FI%iUREOR ITEM � _ FEE �OCAIITV �
��!'f�Lt D.i7 r^ ��L..�
Da�e A licant WATERCLOSET _ NEAREST (
CERTIFICATE OF EXEMPTlON fROM WORKERS' eATti TU6 CRO55 Si. �-^"�L.p1�_j�l,3 C) ��/�
COMPENSATION INSURANCE SHOWFR �f�NF �E'�"�'Z�-�=7 -
'�(This secTlon'need no1 ba cemplafad if the work involvad by --- -- Mnit' r
.�1he permit Is for one hundred ColEars(5100)or less.) , .AVA�ORV ADDRESS � _ 6�� ��� �
�1 tertify 7hot ir,the performar.ce of ihe work for which ihis "
�^.permit is issued,!shall no1 employ any person in ony monner Slh�_ � '__ CITY�' I f ���2..q :r..n:o.y��,l�r,/"� 1
.,••so as to become wbjeci 10 the Worker e ompensotio Laws. --- pISHWASHF.R � �
) cou�kncroR�-�,f-'.e'.R�-l� ��) fi:..�a 13i.�1<
� DalP � � -['pplicant y� ClOTHESN/�SHER 3
7 ADDRF.55���,e3��!?, G7��-', JJ L-��
� N0710E iO�ryl� IF, nfir.r makir.�is ��.�ificate�4 �WiAAMIN(�WU:REf,FPiOR
� ' Exnm �ion, ou should become subjer.t to ihe Workers'�,��; _ caTY `,� ie�.NO6� ��a
�iCompensa�ion provisions of the Labor Code,you mus�forih- _�,;p �ny./NS?RINKlFRtiV9Eh1 ST�TE�'-..-r!�'��j.q-�rCJ- _ `_ �neel"�l
with tomply with such provisions or this permit shahl hr. :,'( _ . =T J` '� /�
��'deemed re�oked. ���� WP.TFR I�IEA1hR LICFNSE NO .�..Z ' `�"� CtA55 ' �`F�
I LICF.NSfD CONTRACTORS DF.CLARAT;U!v � � •- � � - DiSTRic�n0. PeOCE55eo ev
9 . .,,I hereby�affirm thn�I om licensed ander provisions of Chaptr.r 9�'��'� �n55YSTEM _ OUTLE�S — {,�� _--
�;�(commenCiny wifh Se[lion 7C00)of Division 3 0l fhe Business •�'l � OUFIEi50VEN � -'- ---� �
5 PFR SYSTEPJ,
und Professions Code,and my licens�is in full force r.nd eflect.� � ��` — - FiNAL . VALlDATION y:.
L /` ��� ( wV" 1 E+� 5 F.?,•:! (p C7'� �ATE/li.`�.�"�� '_ �,
;license Number�'� _�ic Class ��-�T"�,.���'�.: ` f �--'
� �/ I�. ����y- r�y C�'"(� FINAt r-- �
�!� y A�NJ�P�''.C--l=� E3Y _� �s
� .'�Controelor ���e• __bntc g��T iz ----- _ - — ,::1 i �.� A U
�.�❑ I�m exem f vnder r.c._,_.
8.87.C.for ihis ienson _ ._. -- �� -'--' � �'' o ' ` °j Cl•
j . Plan check fee �
—Date:.._—'--- �V ' CA
� '-- �-'" — �% - Pi.UMBING P[RMIT ISSUING FEE$ _ i U I " ti L F'.J Q �
�� Signature_..--__.___---"- TOiAE FFF. U' � � �����'
: �_ �_�.��. S �.
f � �� � ��Plan check applkon� n';�i )>� S>.7
' SINGLE FAMILY .a _......................_......._.. ....--._ '_ ,..,c.
i }iOME OWNFR�BUILDER DEC!ARATION „�;. Nnme
I 'I he:ebv nffirm ih�i i oni Px�mpi!rom+hr.Corilrnctr,r's€icense :,.c.; ^Va.��� ""'—" -" "�---_� '-
� !L�w for Ihe followiny renson jSn'Iion 7031 5.6usmnss nnd "'e! ._.._ _.. ... .'._--" -'-
Professions Codr.): ..�: C:ity _._____.__.__TYI.No. ...
(''� T.
�'��J I,ns owner of the Nropeny,will do ihr,work und ihA ,��; ►
� s�rudvre is nof inlenderi or ollered for saie (Sr.Uion ..f
7044,Bosinezs ond Prplessions Code1.
�� CONSTRUCTION LENDiNG AGENCY �;i
„I hereby n4firrri that�4�ere is n consiruuion Ir,ndmy agency for
� �'i Ihe performance of�hr.work for•��fvch�his permit is issued ." .
;fSec.3097,G"v.C.�. �•��
p;
i L(?�l(IP,f S N(lR1C_._... .......-.... _____ '.'�.
� i Le;nder's Address_'._—..�—_... -- �.�
f I cer:dy tPiol I hnvc rcrd�h�s oppLcniiun ani:i s�a:e. Iha�th�; ►
� �above infonnal:on�s::nrreu.I nyree to romply•r:ilh nll C;ounly '��'
ir,rdinances and Stato IO`N5 lP.741I01111C�PIUIIII)I�l(�.(111C�I1PfOI)�/ �
�C:I.�If1UlI/F? �AI�fCSI•!1!llli•If.ti I�115�.:IUn�y :J l`�l�(?t 11�JC)�I lil(:
� �•.nb• c nicn:iortr,rl n!upe or�nsno:'ion nurpo•+r..x. . _ .
SEE REVERSE FOR EXPLANATOitY LANGUAGE
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