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HomeMy WebLinkAbout1121A (9) � 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 � ;iiqn�6Pcrm� co ..'.--._ �y��� -, . I�, ,�. P3✓:.� .�. � „,nll:,..� . �,y .._,..^��FC-�' : � � �..,, , w P £k D. �.�.�..�_i:'�?rt.,o . :,•.� ...,, , ,. ,'i..l�'�rt"i:�.'a. a �.rf.-._... � , ,, ' . i..' , , ,.j.";E��,�i:.i.c.�'.�'i'� t?� ��yo� .. . f����'�4��,�i;n���l I t� !nl � � ! '�����IrVLSG�_:,:1;N; I j i � , � � � � . I � j',;'o!„ � 'I ';-� :^�:���z�'�j;�;�1'..i � . i : ' � : ' ' E":, i . I�� �: i '�� ��,�f} � : ` � ' i ' ! � f ' f ; � ' - f��.�� • '��4 :.%im' 17iC� }.�4 ' I I j j i i j ` , . , . .� � , ��i �Clri � 'i,7�0iC3 �s � � i � ; I � , p . . � I , : �l;i�� � �•l ^�,,f � I E ` I � i '. 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