The URL can be used to link to this page

Home My WebLink About1099A (5) �, WORKERS'GOMPENSATIONOECIARATION APPLICATiON FOR PLUMBING PERMIT I hereby,af}irm that 1 have a certificafe of comenr to self �Bp687A � � � ' insure,or o cartifim�e oi Wor4ers'Compenaalio�Insuronte, CE 8�7(REV.8/88) � - � � �' or o ceri�f�ed co y rhe eo�f '�/9800,Lab.C.) ' a�oiicyNo. � � c'e'mbooy��A.� !!d COUNTY OF LOS ANGELES _DEPT.<OF pUaLl ;�� Certifivd copy is hereby furnished. ,\ �. � FOR APPliG4NT TO Flll IN(PRINT OR TVPE) � BUILDI � n . � �. Cert�fied copy ic filed wifh the cow�y buildinq�inapeo- ��` d � / � . lion deportment. , NUMBER fIXiURE OR IiEM � FEE � Q �}�� (�'] ��,��T� �J�� mo '�, pple_LJ 2SCILAPPIitont 3 WATERCLO6ET /� �� pqESi � ,/� � � . �� . , .CERTIFICATE OF E%EMVTION FROM WORKERS' a B��H iUB � �� CR065 Si. 1 I� p 1=l � . COMFENSATION INSURANCE � OWNER . � � � � (Thb�rnton n��d nof M compl�»d ti�h�wo/k I�wolv�d by S��R . ... . . . . th� rmif is for on�hundnd dollan =100 or I�n. � N's'�l . . . . . � W � J ) LAVA70RY A�� , I cenify that in rhe per(ormonce of ihe work for which ihis � ' , . permit is insuad,I shall not employ any pmson in any monner �� TY�p J� � -� L �s . � so as to become subjxt io�he Wo.kers'Compensofion tows. �I DiSHWASHER � CONTRACTOR - 1 B , �o�e ' applicant �- � CLOTNESWASHER ADDRFSS ^� / � NOTICE TO APPLICANi: If, afler making this Cmtifim�e af � b /0 S T/ri�1'J' • � � - � � ��emplion, you ehoold become subjecr to the-Workers' SwIMMINGP00LRECEPfOR CIrY npenw�ion provisions of the Labw Code,you musl foAh• �AWNSPRINKlER5Y5TEM � "�'�' � ' .n comply with such provisions or this permit sha ll be � Si�h �� deemed revoked.- ' � ' � ' � WATER HEATER � �� CLA55 �� ' � IICEN5E0 CONTRACTORS DKLARATION� D�STRt NO. PROCESSED 6Y I- ' I heroby affirm thof I am licensed under povisions of Chaple.9 GAS SvSiEM - pUtlETS � � � � , (commencinq wi�h Sec�ion 7000)of Divicion 3 of the Busineas puitET50vER .. y '� oad Rofeasions Code,ond my licenae is in full Force ond effect. 5 PER 5Y51EM FINAI � � � VALIDATION d (] ��_ DATE V License Number �� Lic.Class��_ S 2�_� a i�C`hP�C 8-a(o-p7 Fin,n� o '� ControUor a�e?r . BY � U I � ❑ I am exempt under Sec. - �. V a H B.aP.C.for rh�s reason plon check fea , _ I Dote: PLUMBING PERMIT ISSUING FEE E � ' Signature , � ' - TOTAL FEE �� 9.9 A � . .. .. . . . . . . � Plon check applicant � �i• • • • •5 � SINGLE FAMILY I ° °9 O S = l � HOME OWNER�BUILDER DECLARATION Nome .. ', .. . . ... ��2.��si Pt c� ZS t .' I here6y affirm�Mr I om e.smp�from the Conhotlor's Llcense .- Addrosa - � - - - - � , /'^•�for the foliowinq reason(Secrion 7tl31.5,Busineu ond � � - � � � � � essioro Code): . ��y Tel.Na. � , U I,as owner�of the property,will do 16e work and the � � ', slrutfure is na1 inlended or offerod tor wle(Seclion . . _ . . . . �, . � ~ . . ' 70U,Busloesa and Pro{ess(ons Code). � � CONSTRUCTION LENOING AGENCY � ' - ' � �� - - - � - I hero6y offirm tha�Ihere is a conshuction lending oq�ncy for � � , � the performonce of fhe work for which ihis permil is issued � - , - � � � � . � � (Set.3097,Civ.C.). . . , � lender's Nome - ' Lender'a Address .. � . . . . . .. � . . I certify thar 1 hove reod�his application and stare lhat the . . . _ _.. . . . . .. � . �_ . . . . � obove infamotion is torrect.I ag�ee b comply with oll CooMy � � - � ord�nances and Srofe laws regulatinq Plumbing,and hereby � � � au�horia raprosema�ives of�his Coun�y io enter vpon ihe � �� , -� � �� abo •memioned p.ope.ty for inspec��on purpoaes. SEE REVERSE FOR EXPLANATORY LANtiUAGE , ��7��,7 � Signo�u e of Pe�mittee Dote _ L . . _ . . . _ ! ... , �, .,� �r ,, _ _ � . . �,, „ . , i .:. � . . , �.. .... . .. _ . , ' .� .. .. � f. . � ,._�. . . .. .... . [ . . . .. r_. , . . . ' . 1 �. 1. ., � ..i�. I �� . � � � n�.� INSPcCTOR"S NpTES � . . � '..— °�,,..I"` ��YifJL�Ei� C��k�CF C S<.-il� �� oucNFuao✓�,is �.., re,.. Jn«•.a S.C^{z UFe -._ ----_....._ -. .., .-_ �..^.. ! f � . ��-` c .'; . � � - - � Un�CER SLAB WO.�K .� �/�7 . . .`T^ � c� n i F [�� !o �.�o<.r r c .��s ./ , _ M6 V ,._. �/ya . _. . . . . ,.... .....__. _._.. l e F. t . ...� .i.(5 f li131 5. ' ' �O- '- ��"I .� . .J,. . , Rcl cnd{'ro(� Cod.. !n cit o co � r i�ch GnSFIP;nU , `•`' • . _J. _.1� � �� , .. .. . Y j s�: r ✓ v i , _ _ „ - - � � :. - -� , � .,,; � � reGoires e fer it ro cona�rucr N . mpr �� h .,_ " ,,' ' ' ' GASVEI-i .�. j .,.. 1 �'.:�.,..", .-__t. ..___�__..' � __ ___"...__'_.,--..:. ' ..._ .��,or repc�r enyrstrucfure, rrio 10 i1\+�iszua ce, a's°f��re� ��O'WAtEF�HEa7E.^.--=.?... �'---'�-> -�-- '� '�"'-- �- � -.� � : ....�— ufras�Fir l�c^•tf�r.;uc� ifoiifnasi� dstc�e� I i...i ,. � i _ i � � 9 cP A. �° � FLU`M1BItIf:Fi%Tt)4E5�';�=i ".� � ,.._ '.'__ ...___'`_ _'_"'_""_ . r c��-;�.. r i _�� ,! I . . '_'_ `_ 'j ?' menf 1f 1 V i�s licc I pvrsJ r 1 inc pro sions of fh G:.STEST - � i�-.�-- ---=-�� - ----- � -� �� --�� Conlraclors[I�rense La�,(�hep� 9.(ccn mencrng wi!h , � UTiUTY CO:-NOT:F:FD-------� ' ' � � �� j Seclion 7000)ol D v s o,3�olYhe G�sinesz c d Pro,,'es� �--�� -�� -�--� �.��-- ---- �j---- - ------ � ��-' `�'--- � � ��slons Codc)cr tha l e -exempt lhercfrom and ih 6esis � '` . �� .._ � ; � � ; l,�r fn f gad e Iion"A y ' ]o! / 5'ecl�o., FIhnL '. - '- ' � ' � r';; - I . � • ' �7031.�i byany�aNF��c lorb� r 1f� b�cus N eppG� ': • ,f.�t .,i, `�r�,d r� ,� � - , , � � 1 i �d.ev ._'_.'.. -'_"__'.._'_ .._._ ....__'___. ._. __ _ ,_. .._ .., ��tcn��lo a civi!pcia(ty-ol�riol. �tha�1 e��hu , - _ ._. _ ___ _.'_ .'_. . . ��. , . . . , ._ .-.. f ., i _ ._ .. _ ' � ' .. �dollcrs(5500J.� . ... . . _ . _ , :i , � !ti7US'F[tl- . �, .�...1�--1'�-'----- . '_.__ _:. � ....... .. -._ _. . __... _ _ _ __ . ❑I,ns ov;n, cf tl ro; r ill da tf ond � _ ____._.._. _-�;`... .JI_.' .__I � � Se � . ,-\ ' `.,- ' _-- ""' - -itro[Jr ts nct i -en�^d c r ri-f.� f � -�� 1 ASTE P F^ A � ' '+ -.'.-. . ::^ - _ i ,-T--..T i• ... �._. . rL'FIo .. ' ?r� . ThCConfYac� � _ � .-S ' - ' c 7D44 Bo lnrss cnd Prolcss ns C d � - --�� ; or's Clcenso L w doc npt o ^y fo ,c,�ac o�p-r'"'-fy {� '+ .. � "� 1 . . i � '� � '. �- . • work h1'msc11 provrd d fF,ol sr�ch 1 prwehents cre�nor � f_..__ ..._ ...:..,..,., .�..'t.� ..,:�'.�, .. __�.., '�- . � ._,_�___ ..._._._. .__�'. � iNend.doro/(erndforsale.�ll-ho�tcver.lhe6midingo� -. Y . ,,. .., .__ . _ . _ ..... �,� ' i . � E.. � � ---.. ,.. ':� �--'�-- im�fOVC!^C�I,Is 50��Wi�.Si�OnC yec^o/mmplc�ion:�hc .. �. • , • • .• . _.}... .�i"---"' : '" --�-"'-' ' ' . ._ .� " , � ,.��-owner-bvllderviillhavelFeburdeq.ofprov,n9fholhAd�d - ____� .L� �<_._. _ __ . _a_-- � ... � . ,, a � '.:�� i `'' nof boild.or Improve fe�the purpose of aofc 1:�� , ; - - -- - ___ _. _._.... __ - - _., - . , , - - _ _- �:� , ,- . : -:� :: .. _ _ — ._-- -- ------ ---__ -- - � • _ `�i �..� --- - --- � . � - ,� - � i �� ' � i - ('am exempt'tin,3 r Scc.�_..�. �_. . ��' �, � � �., ,-. - '� r- �:. - - � - � . . .�- �, . � . ...� �.. �, _,. . .,. � �. � . � _.. . _ �. .�-'�� '.. .r . ,.... ..-. i i _ L__._. . J_.- -" ' __.....___; ' 6-�P C.fcr ihis rca cn� - � •. ' �--�'----'---=...-- �-'----�-------'----_.'. � � •- ---- � .. ........... ..��,�,� � . , . _ _._.,..__- ------� '., �,.�.... _ .. � � � �. � ._, � .. �'� i � ------ , _ -- .'-.. ..__ .... ..........._.._ ... ' -- - - . _. . . --- � .�)_ . _------- ---- � � . � , .. ._ „ .. � Da,�— . .. '-'__.' ,__ _. _- --- �-' - . _ ._..------ ----'--- - , � .. ., �-- �---- � �� --.._...__. _......._,� _ . .._- , � . � ---� -'---- "'.'-.--. _. ..... � .. . � �. I�� . . .. , � . Otvner .. . . . . i-. ... .�.. .... . . .. . , . . .__ ._�.�-�� ._--"--�._ ._ . . . .. .. . . , . � � --- . . . , , :. _... ., .. ,� : . S . .,. , .,... . . INSPECTOR'S NOTES j-- -- - -----. . - ---.� . .. .. . r'. . . . . , � .c . �� .. .r�, . . . . .. . ' "� . .._._-__ _"____ _�...._'_.-'_"_'_ _'__.___"_ .. . , . � _ .. _..... __..__-__. _.-. ._.._.._ . ..___._.._..__._... _. _. � .. .. , , . . . . . . . � ...� . .,.. . �. ... I ..� . , .: , . ,�-�. � ' . . . .' .... ,., . ...... .�r�' .i, .. . '- � -_ __'_. ___ ' . . - ..._.___""____.. _..._�..�.-;.;':•�',..�.1 . _ .-._.i �, ... . ._ . .. � .��, ; � i .. . ''_ . .. ,....:.. .,,....� ......... . . .. . . , �.: . � . . ,. ..,' _ . ,, --,-' ;��;_._.:__-�. . � �.. - ..1 ,. . ��-,- � � , ' 3 . . . . .. . . . . . . �, .'1.