HomeMy WebLinkAbout1345A (11) . WORKERS'COMPENSATION DECtARATION APPLICATION FOR PLUMBING PERMIT {� .,
I he�eby affirm thal I hove a certificole o(consent to self �ap,y��q I�
insure,or a cerfiiimte af Workers'Compensation InSuronce, [E gp(REV,10/81) . _ , . .
or a cerrified copy rhe�eof(Sec.3800,lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
POolicy No. Company . -
Certifiad copy is hereby furnished.
OFOR APPLICANT 70 FILL IN(PRINT OR TYPE) BURDING 'r �
Certl(ied copy is(�led with the co�nty b�ilding inspec- ADDRESS �7/71 8 Bl y p
tion depoilmenl. . NUMBER FIXTURE OR ITEM � FEE � �
�) ��.��TY � b N
Dole Applicanf WATERCL05E7 •V NFAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 Si.
COMPENSATION INSURANCE � DW�R� 'l �L O /L
(This��dlon n��d not b�compl�t�d 1!th�worlc Inrolv�d by SHOwER , .
fh� �rmN Is lor on�hundr�d dollan SIOD or I�ss. M'�'�� �r,� /�yLp�,/�,'y
P I I I f LAVATORY G� qpp��
-I certify�hat in the performonce of�he work for which this Q �y
permi�is issued,I aholl not employ any perso�in any man�er � $INK . � CIN j,�Q�J AX��T l�.�rv�. �-S9�/
:a as to bemme subjecl to the Workers'Compensotion Laws. DISHWASHER . . ��NTRptt�'[+�/ �E� A/"
J d OGr
Dole�^��-��Appliconl CIOTHE5WA5HER ADDRESS ��d� E(7 f �
NOTICE TO APP�ICANT: If, after making �his C icote oi SWIMMINGPOOIRECEPfOR
Evemp�ion, you ahould become subject fo the Workers' f'
Compensotion provisions of the Labor Code,you mual iorth- � CIN �X�� �C� TEL.
wi�h com I '�h such rovisions•or �his e�mit sholl be �AN/N SPRINKLER SYS7EM '
p Y p p Sin ^ C�/ O uC. ,7 J
deemed revoked. � - . � � WATER HEATER ������J� 6/ / CLASS �4 �p
� LICENSED CONTRACTORS DECLARATION DISTRICT NO. Pf70CE55ED BV
I heraby aff'rrm thal I am litensed under povisions of Chapter 9 GAS SYSTEM- OUTLETS �O _
(commencing wirh SeUion 7000)of Division 3 of the Business OUilE750VER
ond Professions Code,and my litense is in full fwce ond effect. , 5 PER SY57EM FINAL � �
!) Q G / ��� VALI ATION
license Number��'1���'/ lic.Closs r^ �S � ���p DATE G� a'
�� ����>JYS z � BY�Z �
�a�,�a��o.S'E'Rvi��pleG�,e -��—p �p � a
0 0
I om exempt under Set. y
B.BP.C.fo�ihis�eason Q�M ��!'s W'
re: Plon check fee ► :'=1 3 4 5 A N
PLl/MBING PERMIT ISSUING FEE S f O Z
$ianon�rn'��� � �J• • e s •5
TOTAL FEE
. . . . � Plan check applicam . J .a e 5 a�j Q
$INGLE FAMIIY
HOME OWNFR-BUIIDER DECIARATION Name � � � ' °���O c:
I hereby offirm fhot I om e.empt from Ihe Coniroctor's License q��ess
�nw r,,.rtie�„n,,,.,�„�. „rce.r,.,,�m�S P�n ..a 0$2 7—8 6
_A,�o..,_ .._...__.._. _ �..e.<..
Professions Code): D City iel.No.
❑ I,as owner of Ihe property,will do the work ond�he
slruclure is not inlended or oHered for sale (Setlion �
70dd,Business ond Prafessions Code).
CONSTRUCTION LENDING AGENCY . . _ _ _ .
I hereby nfiirm ihal lhere is a tonsh�ction lending agency for .
�he performance of ihe wark for which this permit is issoed _ _ _ . _ . __ , ,
(Sec.3097,Civ.C.).
Lender's Name �
lender's Address '
I cernfy�hot 1 have�ead�his opplfcation ond srote that the ,
above informotion is correcL I oq�ee�o camply with oll Coaniy � ' �
ardinonce:ond S�ate lows regula�ing Plumbing,ond hereby
au�horize representatives of this Couniy to enrer upon ihe � � � � � � �
ahove-mentioned property for inspection pur�oses.
� SEE REVERSE FOR EXPIANATORY LANGUAGE
�Z�
Signarore o�miifee Daie - �- � -� � �
b x � � o z
. ' G q G � v' .�,� � A
� ' r 4� �,'. ,�„ :o = �n D
� � �G �' :+ O� � � '� Y s
. � m� ~ O -�+ � p � C � i p
' t' " S O
� p�. O C Di Gl �` `r
� O � - T �
G � N
�-� m0
r
� , l
. � . , . . , � .. 'r �
. . , . � � '�{ �
� . . r ti - „�, m
, � . � . � b J � .
• � . � e. �t..7 Z
� �
. � . - ij��
, � . ' > � `"
z ' . . . . � - � D
� '. , m
� N f
E ..
r •_
� ♦J
f •
. •� r
t �
�
�i
• �
. j� N
` , ' 1 �
. �
�
. �
� f
', '
`' . r
1 �
� �� � �
, . . L_I. � p �p Q n T
�, [l 3 �. N W
. . . - � . n.^ o� U n �y m � C� m 6 �
' � w . '' �� SO � 0 ��W N O O �-N O N M r� .
. . � � 3 � � � » o y��S(�� t; Q 7=i p O O P O .
., ' . ' � �,'p�� lC O N ❑N O � O V� lD 7 f _: C .
�,� �� � 7C' ►��1 C ��'(. O ��^'T� 7�el O'
0.� �p �'� . ��W o q x c m �c p o� ° �����,.v Y 3 a ° 3 m
v 3 N m - ;v
O A' . . �.♦ � , o��o �N m �N o o_o �S Q = o? ^o N o; �
"� °'� _'o '- "- f ' °.
+ c� , o .. � 3 ,� �0 � � � o ? . �� x �-�" Qo� o � pO C
" v f. N � 0 3 dN � o c a n e� �.a a.� '� N o 3 �
, , 3- c o _o a.n-� o ° � '� � .-�s N � �� ^'4 c ° � % p .
: N `..a. t T n..,.Q.' � �-a cs, °o`o x "i�N T a _a-� o O
J' co 0 o v 3
•��'- � '��' . o � � M N °.�°m ,v_ n „ 3 °.Qo `° ' o ^�p Q
T a o ; D m
e o �: nr.��?� N��No � 3 � �sm� 03 N1 ^o o �
. , ..� oc� :,� w,t o o,{: 0 3 n m',a so 3 _. � 3 �
. , . C o m S S� p N c�.2 W - < !�N�W - u•'fl ^ N T �
. ' . . . � . ,..Q �W � 3•p � f1 4.� 3 C �0 �N �� C � � n �.n Z
. . • � ,a O '�'p d� �� O � A j p � � S�p f�'p Q� j j .
. • O ,r,n '^ �
. �.` _ o < o �-3 0=; -��.�. o � ° � n-�' � °-0 3 f w�
. _ m� 3 to + o a ' •'� T w v+m '°'n T N ° o T..°
' . , t0'o � G. O C n p.. a i� n �tn e
` ' . �?�C�n.�'V O � �� �q � _ m� j� :T S.
. i � . . � p O �O u � 3 . � -p O _, r, j.
. , T� j j� C � o � ��> N
o � � � q a
a s o o T't ,�
, ' o,m - -I--�
-�
�i�