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HomeMy WebLinkAbout1102A WORKERS'COMPENSATIONDECIARATION�I APPLI�ATION POR PLUMBING PERMIT � � � 1 hereby,af(irm �ha�I hove a cer�ifica�e of consent lo self 78AB67A � insme,o�a tertifica�e of Workers'Compsnsolion Insurance, CE 817(fiEY.B/88) � � - � �� � � � �- � � � � ' or a cerlified copy ther�of( .3800,-Lah.C.) � � - - � P�ol'�cy N K� 3c�����r�.�-�� �J . COUNTY OF LO$ ANGElE3 DE�`.:.OF PUB41Cy, _ �� ,,., 05� Cenified copy is hereby fumiched. . � C ���' � � , � . FORAPPLIUNTTOfIIIIN(VTINTORTVPE) . BU�IDING / /_�,�� � ' . Certiiied copy is filed with the coumy building inspea °'D�� �� ���'�� iion deportmen4 � NUMBER ftX1UREOR�hM � �EE ; � � �/,�'� LOG4UTV � ��C�.. ..Date��L' Applitant� k�C� � WATERCLOSET NEqREST� + CERTIfICATE OF E%EMPTION FROM WORKERS�' BATH TUB � . . Ck055 ST. ( .. COMPENSATION�NSURANCE � S��R OWNER � - � - (Thb�sMion e��d m�b�mmpl�f�d if Ih�work Mvotv�d by _ . . . .- � th�p..mlt Is far oe•huedr�d dollars(SI00)or lu�.) lAVn70Rv ��L � "� ADDRE55 ��� I cerrify rhat in�he performonce of the work fo'wh�ch this � o _ permit is issued,I shall not employ ony pereon in any,monner 51� � ��Tr ��� ^7(�' / " . I so as io became subject lo the Workeri Compenm�ion Laws. DISHWASHER , pt� coNranaoa i� he Q Dnte Oppli[ant � CLOTMESWASHER - ADDRE55 � ' NOTICE TO APPLICANT: I4, aher making ih�s Cerif�ca�e of 5winuvr�aoOLaeCEpiOR � D l r _Femption, you shoold become wbject to Ihe Workers' ��. ' �penwtion provisions of�he labor Code,you must forth- �qWN5PRINKLER5YST4M Cln � n6�J� - "�.n comply w�th such provisions or this permi� aholl be . STniE �} (� u . :� � daemed revoked. - " - � � WATER HEATER � IICENSE NO. ��`'��Q QA55 j � �� LICENSED CONTRACTORS DECIARATION ! DISTRKT NO, PROCESSED BV � I hme6y oHirm 7hot I om licensed under provisions of Chopter 9 GAS SYStEM OUTlETS � D Y►� I Q I (commencing wi�h Secfion 7000)of Division 3 0(�he Business OUilET50VER .. . . . ' � �a� ond Profess�ons Code,ond my license is In fuU force ond effect 5 PER SvSrEM f�NA� I� 313 083 C..� �'n� Oc� DA7E J�- vau�nnoN � °, License Number Uc.Class � � � - � � fINAI d ; Con�rouor � 'Dota�.$.Z , 8Y V.I ❑ � �I I om eaempf onder Sec, � B.BP.C.for fhis reoson � Plan chack fee ? ' .. . ���' . PLUMBING PERMI7155UING FEE S � �� � O.Z A '� S�gnoruro � , . T07AL FEE� Q(� ' �j• . • •5 ' . - . ... . . � Plon ch�ck oppiiwof � • � O(a S O I SINGIE fAMItY ' I HOME OWNER•BUILDER DKLARATION . - Nome � � � � � , --' • � � ��Jr Q� _ i I he�eby affirm that I am ezemp�from rh�Connac�or i litsnte Addieas ' -- - �� - � ' � , i for the followinQ roo�on(SeUion 7031.5, Businex ond � � 0$2 7—8 7 ' �e:sions Code): � '�,, Ciy � Tel.No. . . . ._. � I;os ownar of the properiy,will do�he work nnd the � i strutture ia not imsnded or offared for ml�(Sscrion � � i 7011,Business and Professions Code). . CONSTRUCTION LENDING AGENCY � " -- � -"�- � � � � � . � � - �"� �� I hereby offirm that tha�e is a construction lending oq�ncy tor � . . � � � � � . rbe peAormonce of the work for which ihis permi�is.issued � ' � . � - - (Sec.3097.Civ.C.). � �� � . - . i . . .. . . . ... . . . . . . . . ... .. ... . � - l�nder's Nome . � J� lender'6 Addrsu - � � . 3 1 cariify thot I Fwve raod Ihis applicorion ond stote tlwt Ihe � .- . ' - .- � . . , � . , above infwmation is corrxl.I oqroe to comply with all Couny . � ordinoncn ond S�ate law�repoiating Plumbing,and hereby . _ . . . _ . . _ _ authorice represema�ivea of�his Couny�o enter upon the '� , � � � j above-menlioned property for inipectio�p�rpo607. � � � . SEE REVERSE FOR EXPLANATORY LANGUAGE i ������ 8�7-g� j Siqaoture of Permitree - pota T . � � � - i i " . . . . . .- . . . . ._... . . . . . . . I 1� �i�' �` � ' + '� � '-' . . . . . . . . . . . l _. �\ . . .. . ...._, . _ . .., __—.__�_'_"'�.J-._ ' ._ ... . .._ ,. . ..... __. ...:.'. ' ...,� ..... �.. .. i .. �t_' _._. ' . . .. . .. . 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