HomeMy WebLinkAbout1466A WORKERS'COMPENSATfON DECLARATION os4�sva � .
1 hereby affirm that I have a cer�ificate oF���s�,t to.e�f �F.,,�,-.a, APPLICATION FOR PLUMBING PERMIT
insure,or a certifcete oi Workers'Compensalion Insurance,or . , ' �
a certified copy thereoP(Sec.3800,Lab.C.) '
3�CI�956 CPVA Aetna CdSUd�ty 5�82 COUNTY OF LOS ANGELES BUIlDING AND SAFETY"
Polcy o. Cnmpany 7 1J11Tt ' � � . �
� CertiCed cnpy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TVPEI BUILDING 550 N. Gol den Spri ngs Dr
ADDRESS
� Cet[ified copy k filed with, e ty uilding inspec ion NUMBER FIXTURE OF I7EM � FEE
departmenL �OCAUTY
WATER CLOSET �
Date Appiicant 7 gqTHTUB 'z OQ CROSSST. �Sll�l$Et CPOSS711J 1
CERTIPICATEOrF.X PTIO R MWORKERS' OWNER The Anden Grou
COMPENSA ION I�7 URANCE �{ SHOWER � OO P
LAVATORY MAIL
(This section need not be completed if the work involved �� 6 0� ADDiiESS 629 Covd�na Bl vd a
6y the permit is for one hundad dollars (5100)or less.) � SINK Z �� ciTv $dIi �'IrtIdS Te�.r,o.5g9_8491 U
1 certify that in the performance of the work for which this DISHWaSHER �
permit is iuued,1 shall not empioy any person in any manner � 2 �0 CONTRACTOR pi el i ne Pl umbi n � o
so as to become subject to the Workers'Cnmpensation Laws. CLOTHES WASHER ADDRESS 12061 Pi pel i ne AVe U
Date Applicant SWIMMING POOL RECEPTOR nw.
NOTiCE TO APPLICANT:[f,after ntaking thls Cer[ificate of CITY Chi no TEL.NO(Z7-7�JO� N
ExernDtion, you shouid hecome subject to the Workers' LAWN SPRINKLEP SYSTEM STATE Q2 LIC. C_ Z
CompensaNnn prnvi,cinns of the Ls6ot Cade,S'ou must torth- LICENSE NO. CLASS
with compty with such provisions or this permit sheli be ] WATER HEATER 'L QQ
deemed revoked. � GAS SVSTEM 50VTLET3 2 0o D�STRICT NO. PH9 CESSEp BV ;
L[CENSEDCONTRACTORSDIiCLARAT70N OVTLE7SOVER �� .�/R.cu��
i here6y etfirm that I am licensed under provisions nf CfiaD�e� 5 PER SYSTEM _ ,, _,.
9(commencingwithSection-7000)ofDivision3oftheAusi- . - � --- --�--�- ��� -� FINAL - � - - � -
�ness and Pmtessionx Code,and my license is in full force and DATE � �� �� VALIDATION .
eftect.
FINAL
�icense N er �42274 Lic.Cla C-36 gY
�i p e i n'f e�g �-�—
Coniractor � Date �
� [am exempt fr�m the licensing requirements as t am a Plan check fee
licensed archifect o� a regis[ered p�oPesxional engineer pLUMBING PERMIT ISSViNG FEE S 32 5�
acting in my professional capacity(Section 7051,Bus-
iness and Professions Code). TOTAL FEE � �
i,ic.or Reg.No. Date Plan chxk aDP�lcent �1 4 b b A �
HOMF.OWNGR-BUILDER DECLARATION , Nama �� �-� � �5 �
1 hereby affirm that 1 am exemDt kom ihe Contrac�oPs Addrass
License I.aw fnr the following rrason(Section 7031.5,Basi- Citv Tel.No. - ' �J�a���
ness and Professiona Code): • �3 2 fl 5 0�
� i,as owner ot�he property,am exclusively contracting � � � �'
with ticensed contractors to construct the project �2�4—$2 �
(Section 7044,Butiness and Pmfessiqns Code). .
CONSiRUCT10N LENDING AGGNCY � � � �
I hereby affirm thet there is a consiruction�ending agency ' ,
for the pertormance of the work for which this permit is . '
issued(Sec.3097,Civ.C.). .
LendePs Name � .
Lender's Address .
I cenify that i have rcad this application and state that the .
abave informatton is correct.1 agrce to camply with all County SEE REV&RSF FOR BXPLANATORY LANGUAGG
ordinances and S[ate I9K5 regulating Plumbing, and hereby
authorize represe etives nf this County to enter Non the
above�e t�ane p�'�for inspec io purposes. �
��/ , �' � Z
Si ure uf P t e Date
� �, c� o z
G � � � yN �N G O �
-c+ -1 Y� � � G '� S 9 v
z2 2 � `a G' Y,5 2 Z r p O
j�G ` n �-i (•� � '1 G1 I C7' y
.. - nNa � O � S - p � N
. v� 2 y� � �
�� O G a � S�
� <�, , T fi � ' �
O `n `1
• f ,� � . - � ,➢ .
�
, � � - � � ��,�
. ;
n �; . 1 N
�/� . ' ' ' Q �'1 �,�� '
.' o � °°' �
. � �� �'�` - �:� � �
,
' � '` " i�
9 � � a
Z ' � m
� . ' �, �
N . .. .. �.r � � .
, N
� .
. � m
, . .: �y
� O
9
N
Z
' O
� .
. N
�
�� �
N r �Y��+-�,N'i���
. y � � G C7� C C n ^ C '+ �
. - �� Cy ^ � �� `. � N '� �
� �'(� �� n ��'V. �..~ '^'� � A v i � .C�
C'C' p n � �Or .�.. C C 'r i� �,'^^ C-a�•G' � r
• ��c �-� =•�`_o� ' c-=c.,c,�r`��^=V � " ^4 G .
. . ,�, .: � C'C . v i" .4.F•v. ��' .n=' � _ � �' c, �,C iru+ .+,
.✓+� ` c T ^v' C C^.1'f: C C,.ti i x ~� ' � ~"s• ~ f ." G
, ff. � " ~. C ` Y%' ' =.. C��. "=q'=' ... � t., cc N �
, C ` ' � f� ��+.'r� . � ....C �' 7 _ �.�r�v� fH O si�v � N C �� r
� .C P , n r, �' '�
� " - " . '^ - n • f,�
. ' !�_ t+ '•�. �' f.� .: %-' �-'� �,,,� �.C^,v..".. Q Y C ... i5 -�' ��' n�.% �
. . � � .r. ^ —" � `� ��`Y p �".. '. r tr C �~ � ��• ^ �C G ^ y h
. . i' � G C G C � � O <. L. `� O�O U� C y Y H'C� O`� 4 f
' . . . . . ' � J - �o _C t-. r,�G-" .c C o `..'_` R+ �^„ y .� ,+. .
' . ' :�� "' -'e ,.a-. r, ,�r' C • �..�p•�e^• r t ?�r fC � - N .
. ' � �.-. ^ .< ..v '^ �'C1' ^,O �. �
. � c " _ c " p o � �„ c, �. �v .+,' �r .
� ' ',• �, � - � Y.c.c� oNc. :% � c � �.' o � �� .1
' / , r� q � r N ',� p� ^..., ,C � � •� .
., . � C� C r C-a _.'^ � C � �. K� L p C ...� � G•'.:: . _..C� O
• ' ' . . ~ G, �' - '�c� ' G i �. c.> - p •�v �, � 1'
� ' � o^ .`�.'• �~ •-�G, „cy c� � ��'.�. ^ v. a � � �
_ � n= c _ � � � � � � c -��� ..
�/. C�= O n
� ' "'�^ ^'.��' %� 't'' ��'a i� ^G � v� �y� C ^^�. ��(!
. . . . ,p " .i� P f. � C C�n C ��
� . , " ri �.".. �� t C Q K�= r 4 lJ�N
1 '�s• � . c =;o� c c �, T 1� ��,�= ,p F:s'^ .
. - - ' . . . r' �' v. i� e; c n t, n ...�t "
n � � � �
. , o�.� � o G o G ...
. . +...• ' . . . • ' ry�'''�ii�
. • . . ' ��
/