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HomeMy WebLinkAbout1101A woRKERs•�oM�N�TioNOEaARATioN APPLICATI4N FOR PLUMBING PERMIT �� 1 he�eby,offiim thar I hove a ceditico�a of con�ent to aslf 7BA687A msure,or o certifiaoie of Worke�c'Compenwtion Insurance, -CE 817(REV.B/88) - -. � -� : � � . . . . . � . . ' ' or o cenified topy Mera�ofj�ec.3eW,lab. .� - � � � � - COUNTY OF-LOS ANGELES � EPE,7' OF PUB IC�WQRKS -PQolicY No. � 3 Company " . . . ;. ,� . .. _ � .. Ceriified copy In haeby fomished.' ' � fOR APPLIUNT TO Flll IN(PRINT pR tVVE) � SULLDING �/_� L . Cenifiad copy is filed wf�h fhs coonty butld�oq in�pec- ��� E� � ., tipn deperfinen�. . NUMBER fIMURE OR ITEM � -FEE r7 iocaurv b � Q�^����p�� wnhR aaser Dote�..LAppliSon� i J NEaREST CROBS ST. � �, , � - �.CERTIfKATE OF EXEMVTION FROM WORKERS' � anTH TUs . . - � COMPENSATION INSURANCE OWNER �(ihis��Nlon n��d not b�eompl�f�d(f 1h�work inrolr�d br ��R C�O - � �A� ..mN li for on.Aundnd dotlon f I00 or I�s�. � 'N'4�t� , . P � I ) L�VA70Rr q�E� �I�. ,I certify fbat in tha performonce of ihe work for which this � �N ., � Op C17Y 6 �5. - permi�Is isaved,I sholl nor employ ony ps�son in ony monne� - � so os�o become subjeu lo Ihe Workers'Compenao�ion laws. DiS++wASNER - . � , � j0 O� CONTRACTOR 1 S C L� � Do1e ' epplicpnf � � CLOTHES WASHER A�E� (� . � NOTICE TO AVVLICANT: ff, oiter making Ihis Carfificaie of . � ��0�� S�/�l'�.T'O . - '� ,�emprion, you should become su6jact lo ihe Workers' SW�nAMINGVOOIRKEv70R Crtv � npensolion pr0�i5�0�5 oF thp LObOr CO(I!,y0U musl IOrlh- UWN SVRINKLERSYSTEM �� P � � � � .h comply 'eh such proviaions or �hia permif sholl be Suh �Oar� �K � � deemed revoked. � � � � � - WATER F/EATER . ��CENSE NO. V CIA55 � � � � IICENSEO CONTRACTORS DECLARATION� � D15TRKT NO. PROCESSED Y I hercby aHirm thot I om licensed under pr6vidons of Chopler 9 Ga5 SYSTEM � OURflS rn � (tommencioq wi�h SecFon 7000)of Divisian 3 of Ihe Business OU71Fi50vER �� � '� `� � �a �� and Fofeuiona tode,and my ticense ia in full force o�d effiscL � 5 PER SYSTEM - - � FINAL YALIDATION d �7 < DATF V license N�mbe�- +,1�� Lic.Clasa� �� V`n S Z3-�8• . . . � � �p „�'� e r,ni o Conrrocror 1`��C •Date V�ab . - V ❑ I am exempl under Sec. C N �� B.BP.C.for this reason ► Z Plan check fee �, �ors: PLUMBING ffRMli ISSUING FEE S � ,�D - � Signoturo � � TOTAL fEE �� � O.� A � ; . . . . Plon check applicant � c � ����T j . SINGLE FAMILY � .. . � � I HOME OWNER•BWLDER DEGLARATION � Nome . � �� . .. . .� c� , I heraby affirm thar I om eaemp�from ihe Contrac�or'i ltcense .� p��eu - � -� � � � �� ��'�2 7�(j 7 . 1""•for dhe following roason(Seclion 7D31.3,Bu�ineu ond � � - ,eutona Code): Ciry � Tsl.No. � � U I,aa owner of the properiy,will do the wo�k ond�he srrodurs is not in�ended or offerod(or sala (SeUion .. � .. . . . . . . : ► .. � . � 701I,B�sineas and Profesaions Code). � � � ' CONSTRUCT�ON LENOING AGENCY �� � - � - � - � � • � - , I hereby affirm thot/here Is a corotruction lending agency for . ' the performance of the wwk for whlch this permi�is issued � - � -- � - , � � � - � � �Sec.9097.Civ.C.). , � �� flender's Name . . .. . . . . . . . . . . . ' Lender'a Addreu � � � � 1 cer�ify fior I hove reod fhis opplimtion and slate fhal Ihe . . . . . . ► . . . _ . � obove infamo�ion is curect.I agree�o compiy wi�h all Covny � � ordinonces ond S�aie laws regulo�ing Plumbing,ond hereby � � � ._� . . oWhoriz�rapresenfalives of this Counly to enlsr upon Ihe � � �. - - � obove•mentionad property for intpeUion purpoeea. i SEE REVERSE FOR EXPLANATORY IANGUAGE �� �0� ��7- ,� � �ignorure of ermittee po�a . � . ,.l . „ ' �. .� . .. _' , k ` �. ., .� . . , , . � . ; . � �,,. ;;., .. . ,._. . , �., ... , ,:.: ;, , �. ,. . , � ACFR.�L'ht5 � PATE vSFEC"�7 5�iG�{ATURE SFECiOR 5 I�OTES - - � - � �� ��) �JcR G DE ��C L F �i I7 , , Uf�CEF SLAB W RN �� ��' � � Q�-- � � � ' `� � � f � 2 � � , I J f. C " �� � �.� -.��1 _ ; r� tfl�`t1�,lf IU .� -� 1 f n�i., C n s R011vH FWMB uG.--..- . ��-c70� . ....-.�. .. . .... ..._.....__.. .._..{ L censc l f ,�ho o � .$oC C 7[131�S, .«_ . _GA54`IP.•:-.r.. ,'. . c-i��Pr�� -�,. .,y� „i '��:-. • ��•..� . ..� B I o dF fo. C d !�A r �ry � I�y'lich � GAS VE��i � . � �, � �_ . .� � �- .�� I � � . . - . ..q�irc- Q .�if} � r cr. li 'I t. .' {l��h N0T\VA7EF HC4TFa-.-_ � � � "Tt. '.._� ..l . .. 1. .. _ -.- . ! a reP y t �tf p r 1 cc I re� _ . "_ . ...I ' � . �-' i .MrJiIf31h G�k�( (1�f .5 h pC M�l'� / ^ I+C 3 G�,.IOfe� ClUM.B'�.t:�FIXTlJRcS'( ^ �—' ' '-'_ " � :.�- . ._.. 1___.` . . � , x i; ' r .�...r i.. � . . r. -�1 '' eni ih h 1'r sedp„rsoc r���1...F o iro�s o1 rn�- � � - �``� � � ---"—� � Conficctors:(Iren d L ��Cho t ��9;cortimencin ii!h �. GASTEST ,. ' ,., ' t..___'_'_"_"_-___""_ ..�. _ _ ' . .� A�� I n v _. . �, 'i ����, ` � ! ��- ���', i ,. SecHon 7CC0)o!D s n J��of If e Gusines and Profes� � . UTI11TYc0.-NOi�fic'D__.� _"'_._�_' _._-_'_ .�...._.._ .._ .� . k , � . . , . _.. ... . - ..--'.-.. ...-----._...- -� ---�---� .. ._----�� -� s�ons Cod c fhat f .r c rpt tn rel�om c 3 rh=tiesis � ,; �� � I� �ar�rn��otieg:,d'��. �,�,rr�o„ �„y�v or�i,o� �i s�cro„ FlriA. . ` . \� _..f! 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