HomeMy WebLinkAbout1417A �
WCtiRKERS'COMPENSATION DEGLARATION qppLICATION.FOR PLUMBING PERMIT � � �
I herq�o1n'rm�hai I have a certlficore of consenl to self �bpyy�q � �
inm 1;•,or'o ce�lificote of Workeri Compensolion Insurance, CE B17(REv.16/81�
or a ce�i�eod co8y ih epf,�(Sec.3800,lob.�� COUNTY OF LOS ANGELES BUILDING AND SAFETY . �
O �7
P❑olity No. ompony � ` ._ ,
Certified copy�s hereby(vrnished. BunoiNG
FOR APPLICANT TO FILt IN(PRINT OR TYPEJ ADDRES$ �
�ertified copy is filed wiih ihe tounly building inspec- NUMBER flxtUREORiTEM (D FEE
lion department. - IOCAIITY �
n I WATER CLOSET Q"�J �p
Do�eT�� —�7 ApplitantM�I �'1�C�iYI . Y � � NEAREST �
CERTIFICATE OF EXEMPTION FROM N�ORKERS' � BATH TUB ' r (l�J ��ST' N �
COMPENSATION INSURANCE OwNFR � � R 0
(This s�cfien nNd no1 b�compl�t�d II tha work Inrelv�d b� SHOwER �" e�
fh�p�rrtd�It For ono hundnd dollan(5100)or bss.) lAVA70RY ApDRE55 �C� S y ' pYJ D D
1 ce.rrify that in ifie performonce of�he work for which�his J61� / I
permit is issuad,1 sholl not employ any perwn in any rtwnner � SiNK -u CIN� � �b TEL NO. jy �p p
so as�o become subjec��o ihe Workari Compensolion laws. //_ DISHWASHER � 6 Q Q
r) CONTRACTOR
Dote epplicant- - CIOTHES WASNER
NOiICF TO APPLICANT: I(, afier making fhis Cerlificote of ADDRESS {�,�.
Ezemp�ion, you should become subjetl to the Wo�keri Sw�r�urHNGPOOIRFCEefOR 1 ,
Compensation provisio�s of fhe Lobor Code,yw must forth- LAwN SpRin�KIER SVSTFM ��tY N TEL 1 O O
with comply with s�ch provisions or thls permit shall be SiATE liC.
deemed revoked. . WATER HEATER LKENSE NO.s� ClASS
LICENSED CONTRACTORS DECLARATION I DISiRICT NO. PROCESSE�BY
I hereby offirm thot I am li[enspd under provisions of Chap�er 9 GASSYSTEM OUTLETS t� �n
(commencing wi�h Section 7000)of Division 3 0l the Business pU7lET50vER j� �
� ond Rofessions Cade,ond my license is in full force and effect. 5 aER SVSTEm FINAI �!�� VALIDATION
� � �, �yI - DATE —..�r p�,,,��..
license Number�Q �G / Lic.Class L.,L O
/_ p-7 FiNa< <1 4 1.7 A c�.
Conlrador l��A/ (`��l�LL� Daie 9�9�o/ . . BY �• � • • •5
�
O
❑ I om exempt under Sec. � � •9 2 2 5 0 U
8.8P.C.for this reason PIOn Ch2Ck fBB , • ���7_5 0� d�
1e� PLUM6ING PERMIT ISSUING FEE S �(� 0 . G 9,C 9—8 7 ��
$ig�at�re 4�� �� t
TOTAL FEE �
- Plon chetk opp�imnt � -
SINGLE FAMIIY
HOME OWNER-BUILDER DECLARATION Name .
I hareby oHirm thof I om erempl f�om 1he ConlraUor's license ,qddress
law for ihe foliowing reoaon(SeU�on i031.5, Business and .
Drafessions Code): ���y Tel.No.
❑ �,as owner of ihe properly,will do fhe work ond the
shucture is not in�ended o�oifered for sole(Settion � ►
70A4,6usiness ond Proiessions Code). .
tONSTRUCTION IENDING AGENCY � �
�he�eby�Nirm thal ihere is a conslruclion lending agency for . �
the performance o(the work for which this permit is issued
(Sat.30v7,Civ.C.). -
lender's Name
Lender's Address � �
I cerliiy thot I hove reod lhis opplicotion and slate ihat Ihe , -
obove information is mrrecl.I aqree lo mmply wilh all County � -
ordinances and Stole lows reguloting Plumbing,and hereby .
au�horize representa�ives of ihis Counly to en�er upon the - � � � � -
obove-mentioned p�ope�ty(o�in5pec�ion purposes.
j —8� SEE REVERSE FOR EXPIANATORV LANGUAGE
Signoture of ermi�tee Date �
� �
� o
� �, � o � �^ � N .
v�, c , � "'- s. � v
�^ 7 ��'' � �..'. S' Z� �: v �
w t
• yii �. ' - .� � �. � �, � � U
� �G ' - �' T " i ��
• ri •} O ? O ry:.
� �y'N '? �� y ����y; � �'
_ �z. • c• � � . "\ .
- ��- r'� U n,. �„ i.
r� . ` � N
`G 1�,`', " u,
; � U ��, �
. � `�� ,`• ,_ �r .r �,� ,�`rJ
" . , � . ^,�•=` 1� � 1 r� i„
' _i � '�i ' '\ ` r��
\ . ' `� i
. ` - . ~ � , � � '
' \ � • .w' i� /'
'. - z ~• �� n
` M �
� "� o
7 - - - �-' u�
� _
� ,` • ' �c ! q
' � � .- I r - '� n,
. m � .. ' r� . I
� � __ '
t�
, _ N
�
. �
A
N
2
O
m
N
/ k;
,:/ P �.
' � O iD M ^p N•'
\ ...�n � OfjC' C7Nn� ' .
f'� �� O �� �, N�� �i,. � <�
' � e � S O �W �N O O T ��N Ct O ����
� �� S�'n u_,. tl v�[J O v O " ��Q'6 Ci-� �! 2.
' O �["O Po T."� N J �N n K O f�O N N�..`� ^ �' 0 3'�'L .
�. � 7 B'� O�!tA O 3 p ��' ,m17
.c o .n c �, a o � o
� Qo � 3 �' cc o.?� � ' N o c,-'� � o„ �o�� �' o ' G�
\ p ' � NoN..M W°.o� —o a.T-..� �i �_::.° '"- , C'
p o �o ,cu n.c3a ,� � c � oo � o � o o �
f, c� n �� o awo -^O o � � � o�.x ��."„o °� � � 0 3 �
'7 � 3 ,A,� �a � N °� Q e+ ff n � � n-N � n � �7 �3
�-p 'd p � K"'
° o -0 3 £�" 0 3 a.�, ;o� �3 N � � c 4 ,
� 'O ... N fh <.'17 O �C 'O � .? �C.7 fJ � f,
C o c o o.� o � c� 1D w N o .� 3'','n
, , N O- �m c 0.'��a.o � .n",�p-N -^° ? a °o p o o D n�'' .
�, wf' N '" ° a�O O ° � �°3 3 °.�< N �' '{�
� 1 W .� T� y S p � O 9 �� � O � O �.v� � �.7 � �� f )
' � 'o sa � ° ,� ovN �� 3 " -'< ; a, .o�.0�_.3 ,� '. .
� �' o v� ».�o-7, o �-Z °4,3 < �N �''° ���O o�o•� 2 _
, �o o T � o � f, o o'o o ;, :♦
` � m�O � n4� TCO° N3oa ' � O o' , �`.
.. . ♦ � 0 O O S'D•�Q a-O O ��? O O � N?'n dC y7 \
, • ' av °.� ro £��� o ? `< `" o °'a�Na.°o � wo
0
� . °� 3.� �� ?a� o c q � v°4_o � � ` S� �
' ° co�a �N ov c� r. y-°o = ° m-:-� �
`�=lU �. l� � � 'O p N Y .�
C u� O io :
a -�' o-� �o �
' � � 5 � N ,y a � a ,.
. , a.s o o s•i �-
, a� -.
. Ji-
,4 ' ' /'/'/./
��//'��
�`
�./