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HomeMy WebLinkAbout1626A (9) , -.,i ":..i- _''.F. .•� • . .��.� :��.� .� ...:: .,' . ... � ... . ,.._ ... . ' . .. / _,.... . ... .: - r .� .... . �. ,.r.- � __ .. ,' , .i :.R�..iz. -.. . � ;: � �WORKERS COMPENSATION DECLAkATfbN�� � �pp1,,CATION �O-R,PLUI��ihi�G��P��RIVII��u e :+ I hereby�pffirm thai I have a cen f�co+e o1 consent ro self �yqCblq ,� �, • . , . - ��. ' s e o a certifimte of Workers'Compensation Insarante, CE8171REV.t0'el��� . . , "3 ;;.or a�Ce t�fied co'p•y'thereof(Sec.3600,Lobt.�Cp.) Cp�1NfY OF LOS ANGIELES BUILDING AND SAPETY 3��Pol No. W� Company �V !1�� . ,�„, .:,.�,1-.�1.,*-r „'b"' _ ,�e�m<.y,��, [/I Ce fif ed ro . .. ...�_. . - .;.r.«.w. �-r...,.._:..< ...�....,::.. ��`e�9.��1�.,�. py is hereby furnished_ ,�Y� 8 N ^�� "� -' '" " " � FOR APPLI�ANT TO FI L IN fPRIhT OP TYpE� BUILDING �'I��,,-D � �Ce tif ed copy is f�led wdh ihe county buiVding' Spec- '� �� '�' ' -- A�ORESS �/'�+1„!!�S . ... .. _. •� t o depa�finenf. NUMBER iIXTURE OR iTEM ,� FEE ���A��TY .f �...-..,. � .<.. - �Da1e ���J A I<ani i WATERCLOSET �� . � � ' ,� ��� PP . . � - NEAR�ST . �x .�x....-.�.�.�.v- .,. - . . . CROSS SL � . �T �,r�C�t'f�71FICATE OF EXEMPTION FROAA WORKERS' 6ATH TUB n-� �--� �-�-�-�� �^•-��>���'-�^�+ ��•�`�"�-"�+ 6 in" .:xa'� �,�OMPE�1SAilON INSURANCE SHOwER OwNER� c: �-�/� , �r r��Th1a secbon nead not he completed if ihe wark involved by r�A�� ' /� ' y-�" � 'N"'-' - h perm f s for one hundr¢d dollars(5100)or less.) �qvaTORV � ��f �(,�,�1�QAI�(,(�(�Y/' � [i`C/ ADDRE55 ` f e t fy that hhe performance of the work fo.which hMis " . �,` pe in t ssued I sh II not ploy a y p son in ny m nner SINK �CIT r7_ � TEL NO. � Ao as io-become s b�ec to ihe Wo ke s Compensat o Laws ,�y�� ,a.� s .,.�y��,n.,,.�'-���.�.���?�_; DISHWASHER CONTRACTOR �. ..T .'<:� , ,���Da�e ...s.�; --. ApPlicant ..�..----w QO'HE<WASHER �ADDFE55 � �„5 � ��11�0'7"f�YO liPPLICANT: If, ofrer making this Ce t f<aie ot _� Exe pi'o , you should become su6ject to the Warkers' SWiMMMGPOOiRECE�OR - �CITY TEL NO. q�/C� ;.'.-���..Gompensofian pravisions of ihe Labor Code,you must forth- LAWN SPRINKLER SVSiEM .... ...5�I 1�( ���,;'"wifh comply ith such prov�sions or this permf shall be STATE q LIC. r� ��de med�e ok d , ..,,,,..,, .�-���.--���-,�.- WATER HEA7ER � � IICENSE NO., (�� . C1A55 �r��o t'" .+�.�, � -�LlCENSEb�CONTRAC70R5 DECLARATION�� � �'�` DISTRIC7 NO.�-�-� 7ROCE SED BY -�I he eby aff m that I am I ce sed under provis ons o{Chopter 9 GAS SYSiEM OUTLE75 � � (commenci,ng th Sechon 7000)of Drvis�on 3 of the Business OUTLETSOVER � "`- � '"'`- q�y �'S#`a d P ofess o s C d d my I icense s in ful I force and effecf. 5 PER Sv57EM FINAL VALIDATION � �.F�:�`;€''`ti q/ ]�(/� DA7E %� ��;L ce se Numb �� a °�`� Lic.Clpss�� a�_� / �� � �'3.� "�,,�-5. �J�� �� �"�° FINA '�}r G�onlracfor� O � �—'u 1 �P , BY --- :� •" ;.�s , � ✓.� ,❑ I a ex pt de e ; w y�y _.uy�^ �.�'�.-�yYa` �'t^yy�k-.s. - . . . - � . z�B`"$P C fo ih s easo ` ;.����H �,���-,, ,��. �u,� a�« P!an check fee .�, � � a>t `�- D��e � PLUM8ING PERMIT I5SUING FEE$�� �'>' i5ign t re .. ..,... . /!���5 t� .. " t r-r (,� , � �5 C � .,� k W , . . _ 70�fA1 fEE ,. ,�c ��� �� •J c O H ,. c �. yq� �ac`,y �'3����`,���'',����.¢•���.�'-�.?�"�� Flan check opplicant. ,.;t, {;i a o � a e� � }`?� �'�.�.a4..�'��.SING[EFA/v11LY � .. . - . ...... . ��.;: � -,�. fr`: H6ME OWNER-BUILDER DEQARATION Name .,.„ .. ...,�,,, I = a C L.��7 ,.�.$I`he eby aHirm that I om exemp�from the Contractor's License qddress � ' ' � ,�.,.;:�Low for the following reason(Section 7037.5, B�siness and . �-u^�-,�- T..�' �' •�^^-�%�^ �.."" ' „' '���'l:a ��-,;Profess�onsCode): City Tel No . . _.__..,�...: a,:.w.� .....u-...»..,,:,..,...s�..:...,: � '" 4 ,.�❑ I,os owner of)he properfy, 'll do the work and ihe G /���4 �t uctu e s o1 � t ded o offe ed for sale (Sect n 7044,B�s ess and Profess;ons Code� ,..�; � �����"�- �""'�'g"�'��► =. - �h,..:�;,,�;....�Y?.. ' ....- ._ ...r .,.�,sn.� ....<.s',x,-.,�., . . . _ .. :.. �.ti.:. � � � " � �� CbN$T�`UCTfON LENpING AGENCY �I h by ff ih i rher c n f t n lend ng ogency fo . rhe pe fo mp ce of the o k fon c�h th s pe � ved , , ...� ���_.�t - - . - �, - - � � (Sec 3097 G C) . .. �. . '� � y; � _ . - . � . � . � .. � � r S! �i �_-, -,y .�,�.� , r��,�*�.. :��Y �s"` r,s.,. ,�-�i �°� �, �a .. � ,y�.9.�b�.-&a�. �'t'�u.t�sua.�.ra•�'�`�-afisL'�e. ,ea Ga.:�eG�,wa.�.-r�:a�.1.. -3.• ���Le de s Nome . . - ...r,�+�rf wxsc��cs+k'�+a.�5�n-�, . , ' � -,.�_v. .. . _. � : s .----�---.- . . -x ).,J«- 2 t . , _r.. . ...+�.w..a ks. K-r. . _ -' ._M.,Sx'R.. �.�%n` '�<.a+_.'X;.(4 C kS A.,.. '.., . . :i!.... .. .Y . .� 3.a... .. "" ,. x�:'b.'ii�..Y.-�'$.ea`�'.:�'kR.�hs'.vY� `rtFSSY�4M'+a2YN:ai::'i.rn k9:..:-'1'.S�M .'�^ti.,�. 'Lende Address -'�_- «+�'�- -�.-w � - �`�� I cerl�fy thot I hove read this appl mr on and state�haf the � ,j;:;�j,;��,pbove information is mrtetl.I agree�o comp!y wifh all County .,,�.,:... brdinqnces and Stafe laws�eg��ating Plumb�ng,and hereby � '`'�"`�''outhorize,represernatives of ihi County to nter opon the ...,...._.. . , , .,a e-m nt) e proP r r n Uion r . . . >. � .. . .... . . . .... . _.. .. . ,. ..- � � SEE REVERSE�FOR EXPC�ANdTORY LANGUAGE �17� : ' -' Signoture of erminee .. � te , � . _ , . ��' _;.,`• - � � - ' � .:. .. ..,.. ... .. . . - , :.. . . �: ,. ��,. ' r ' . , .. ,.... ..... .,_ .t;s.:-;. .,. ' ��:... , _ ... � . � . . . � . . . . .. " � _�. �� � r-� 4�" � r g �:r�: - . . . . . ' . . - k.d �a.� � w a;•,:.•S �.al' ��b. ,�-�.C . ` .. . . .. � nPPRovn�s�� oAYE.. . �"i�75P�CToR'S51GNA7uae� -'. .. �� .� - ���'�.'' �NSPECT6R'SNO7ES -.. . � ....� .�..,. �. . OWNER SU 7.UER�DECMAk,4Tl0� .. . . U�DER SLAB WORK `�' � G., ,6 � Y!�ereby ai`.irm ;hat; mpl`r m the Conirac�cr', RDUGHPLUMBING�� � -"- . � Licersr, l.a�•v `or tna foilownn rcosor, �Sacfinn 703]_5. GAS PIPItYG''' " ` '� < ' .��. ' � ' Business and?rafe:sions�odzJ:Any:i�y��r ccun7�whi<h ....:,,..e . . ... .. . . . -��.�,�.�. __ ' ' GAS VfN7 ' c � � � �'�"- �'��"� - -. ���- ' - � �tquiros c permB 7o co.osfruct,niter.improa�e,demolisn, HOTVJATERHEA7ER�- - . `or�r¢pair'any's}rOcture, prio;lo i!s issuance, olso re- . � . ..... -. . �qulres ihe appl7mnt for suclo p6rmlt to/Ife�n signed stc:e- PLUlv1BING FIR7URF5 monf fhof he is licensed pursuont io the provisions o/hhe GASTEST ' ' : . . �..-'. ..'.. .... .. � ..... ConlracPor's License iaw(Chapter 4(commenc�ng wi4h UTIGTY CO.NOTIFIED � '-'-�' SecTimT 7070}of Rivisiott 3 oi the dasiness and rrofes- � , , � . , _ . �-c'w, � sions Codej or tL•ct he i,ox�nip��her�fram and tho ousis � - for ihe o(laged exemption. Ang viofotion of Seciion � f ....._.,,... `'iNA� G�fer on �ronf � � - ' � � � � � � .. _ �� 7�37.5 6y any cpplicant for a permi:subj�cis fhe uppli- � . „ , ,.y„ . canf to�a civif pertafty of nof more fRan Iive hundred ..� ..`�.. '.`.�..:` - � doflars(SS00j.: . , . . . . ., .. .... _. .... � . INDUSTRIA! � ' � ' �� �. - ❑I,as owner of tiie prop=rty will do=4iE work,and - WASTE Aa?RCVnL . . � ����-- . � - ���- ���-- � �-��. �the structura is noi intended or oifered for sa!r�. ' � � ��..^�-+ �� �� ... . , .,., - ;., /Sea 7094,8usinessandProfessbnsCade: TheContrac- C. , ; .; '. ; ''' '�"�I�; ' ., ..'�-�,. .:::-,-..� .. . ;.:. .' � . . � s License Law does not oppfy to an owr,er of propeny ..... . . .. . . . . ,...,'-, . -'. � .. .. � ...; .. . . ,�. .�....... . .. : ��.. .�. .�. ....� .. --.�:'�. '�v✓6o builds or improses thereors, and who does such ; �.. �•'_ � .. .. . - � .- : ,� :: . � . . . . : ...-...,.. . ..:_.... �;-: -, __ :. _ . _ , ,,,, „_.,�.�,_, �;_ ,.... - , . mself rovided that su h mp�ovemenis ore . . .� -' ...:--. � �' . -� .::." ;'..:� . .. � .::.:.. .>:-.�.' : ..`.. ...... . el�doroferedforsole.tf,�however,thebuildingo work t � , � . - : �.. . .. . . ; ., - � . . .. ;,, � _ ,.. .. - ��., Mtend � , : . , � Imp�ovemeni is jold within one yeot oF comolefion,the . � . '. . � - . .. �.. . . ... : . . ,.,. _ .. . , . .,,.. . .. .'..,. . . .. .... ...... .. ......,.,.. , ..__ . .:._.... ...' ....:. . . ., . . . .... . ....owd�r-buifder w%1[hava the hurden of proving Inca he did - � -.r.�: - =.,. � �.� .�� . , �::':;.. � .'-., �;.. ..-.. . . � . no4 build ar lmprobe'fnr ifia purpose o.`safe.j �� � . :...._ . .,.:. .. . . . . . , . . .. .. ..., '. . . .. . . ,. . .. � . , . � .. , :-�-, � : . .� _. , . , . ,. . .. . �. � . - z� � . .. _ . ".�._ -...... ..� .... , ' . , ,� . � � � � . _ ; �. ..�.,,� ' . i�_ ,,...:'�. ..�,�... .... ,. � . . � . � . . . , � � � � -"" I om exempi under Sec �,, . . - ., � .� �. � : , ._ �... .... '��• , _ , . ... �-. .. : , ..- . . . . � . . . .. � --. . . s, ..,.. .---. . . . .- . :.: , . �: .. .� -�=...-:..:. . ;.�- - - � � . . - .., . � - �.� � ., . . � ....-..:.:. ��... .. ;_:.� . �...��....... ... ._. �. ;�._:�... ....J; :. � B&P.C.for inis reCson-., � , , _ ... .- -.. .; . ., . _ . . . �.. _ . .. . � . ,, . ., ;... ��,.; �: �. . . .. . _ _. , � :_ .. � .. - � . , ... . � . , . :�.-� , . : :.. �.:. ��� � Dafe .. . . .. ; ; .. . : , , ..•„ ,. . .. . , - .•�. � . . , . ..._ . � . . ._ ... .. ;.�. , � .. , . � � � � �: . . �_ . :��.: • . Owner .. . .,, • �'""- s _ - . _.- INSPEC7�R'S NOTES __ , ,._,..,.. . _, .. x .. _. ,. .,. :.•. . � _ . . .,. ,,. . ,. < �x> .; . . . . . .. �. �. -. :b�.v. �... .. . ;... . ,..:.. ,,,s- ��+.,..:., - � ' , __ . .. . . _ . ..�, ... . . . . . .:A ...,. ,.. . , . -:- . . '.-� ,. , ..,� .,,. .. :. �, .. ::. -. .. �.�'.: , - ., ,.,,,.�,.�-�.... �:...,.,,.., , . ... . . ,. :. .. . . . �.!>: -.�w+-aw.r..,..-av . .. . ,.,a .._,�.. _ ....,. - ' ,. , , . . , ,. .. . �..' ., } . ... �... .,,:�... _ ,a .., . . . ... , ...:'_ .-,.-.�. ... ._:n ..rt� _.y„-. _ , - . ._.._ ..,,m,,, - .,: ,: , - . .- .. �. _ . -. Lr.,:.,.. .-..:.. .. . , . _ '.> . . ,; .. .« . . .. .,...,... .. .,,,r.. �.:r• . . . .:_. ,. . , . , . . ,., . .,. _ ,. ... ...... ,., _.. . . .. . .., � .. .. ,... , .;,.� �„ . , -,.. . ... . .. . ,-.. .. �. �... ... �� -„ ....... ,;.:, .' . - �..:�; ", . .. . .. , . .:... .....�. . ,_ '., .. .._..,.,.� �- . . � � ,. . . - • - . . . . . .... . . .� .. . , . � .... .,.. -..?sr.. :•.. .,: ... " � .. . . . . . . . ,,� .. , � ; .. � ,... �-:�. �-:::� � . ' -.. .�. ,... , .,, .. ,.... , , ..-._ .,.; _. . . ... �' ,_ , ' � . -.>� .. : , `� . . �,,,r�x�.g � -�"�. ,.. , .,. .. .�, ._4, ., .,� . ,:•:a,,.,s-^+n ,.��.�_�F.r�:� ,