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HomeMy WebLinkAbout1103A WORKERS'COMPENSATION DECLARATION APPlICATION FOR PLUMBING PERMIT /-� i here6y,affirm thot I hove a cerlifico�e of consent�o seif �gqgg7p �, v�� . insoro,or o cer�ificote ef Wwkers'Compenw�ion Insuranca, � CE B77(REV.B/88) _ � �� �� � �� � - � - " - LJ ' w a certit�ed co �hen �Sec.3800,Leb.C.) (��p� � �,,�1- ` CGUNTY OF LOS ANGELES pDnEBT. y), ��BLI^C)W�Q K�S/�. [� P�ol'�cyN�� omppny5`� �l7(�C1� . .. .. . - � rrJiCf Y'��=J G-V�.Y "`� .. . Cer�ified copy is heroby furni�hed. 8������ �. .� . � � � FqR APOIICANT TO FlLL IN(PRINT OR TYPE) , A�E� ' � ` f-(�� �./� . �Cer�ified copy is filed wi�h ibe coun�y building inspec• tio�depanman4 NUMBER FURUREOR��EM � FFE ����rr �,, �O j n /IC'{ !� Q p WATERCLOSET � � �Q .. potev�AppVitaM � � NEAREST � - .. . CERTIFICATE OF E7(EMPTlON FROM WORKERS' , p� B�TH iU9 ��ST' m � � � � CC)NIPENSATION INSURANCE SHOWER - ��� �- � . - (Thls��ctlon n��d nof h�tomplN�d(f Ih�rrork Involwd b� ��i . , . . . . - th�p�rmN b(or on�hvndnd dollan{it00J o�4as.) � �s,v�Tpqv a qpqtEu � ' . . I cenify rhm(n fhe perfwmance of�he wwk for which�hls . . permit is ioued,I sholl not amplvy any penon(n a�y monoer StNK C�TY U• � _ �o os lo become subjecl to the Wwke�a'Compensotioa Laws. DISHWASHFR - �� � � ' � U� cos.na�croR ��C'h � Date ' e�li[onl . . CIOTHES WASHER - �Q A��� . . /�. Q .<� NOTICE TO APPItCANT: If, ofter makinp lhis Certiftmte of SWtMMINGPOOIRECEPTOR ( U ,Exemption, you ahould bemme aubjact ro th� Workers' � GTY / ��ppenw�ion provisiona of the Labor Code,you mua�fo«h• �AWNSPRINKlER5Y57EM �� � � - O .ih comply with svch provi�iom or this permil�ahall be 57AtE q IIC. r�`_ � � deemed revoked.� �� � �- � � � - WAiER MEATER UCENSF NO. .]O W55 C�3 Y/ � UCENSED CONTRACTORS DECLARATION � DISTRICT NO. ; PROCESSED BY I hereby akism Ilwt I am(icensed under provisions of CFwpfer 9 GAS SYSTEM OU7lET5 p 1 ; � (commanciny wi�h Secfion 700D)04 Division 3 oi the&Aineu OUTIETSOYER . � � �Q d � O ond ProFexioas Cods,ond my licen»Is in fu0 force ard effxt. 3 PER SrSTEM FINAL VALIDATION '�(� (!1 K . DA7E G 3�0/.fi�j V Ucense Number�t��� lic.Class�� � � � � � �r- FINAL �}�� � � d Coniroctor �� •Date_�]_ S�� � � BY U/�`•�j�"�j U ❑ I om eaempt onder Sea . . . , � . � W a N e.aa.c.fo.ihis�acsoo Plan check fee ' � z � . ���' .� PIUMBING PERMIi ISSUING FEE S .' Q s� . ; � ' ' SignaWro TOTALFEE . � ' . . . . . . . . . Plan check epplicaN � � �, ���� Q'J A , SINGLE FAMIIY .. I � HOME OWNER•BUILDER DECIARATION Name � - � � � . . .���-• •�• • �5 � � I he�aby offirm fho�I am a.empt from the Contrador's License . �fe�s � � � . r'�for.�hs followinq reoson(SeUion 7031.5,Builness ond � I � ° ��Q Q 5 Q � .euioos Code): Cit Tel.No. � ' ❑ I,os owner of the o rt wlli do the work ood rha Y � � � • °, C�v Q v W Pe Y� , srroc�u�e is noi inlended or offered for wle(Section - � � � �� � ► - �- � � ., - 0 a 2 7'�8 7 -- 7W1,Business ood Proiesaioro Code). � � , I - � CONSTRUCTION LENDING AGENCY � � � �- � � - - - � ' ' � � ' � �� � � ��--- "� �� I he.eby offirm that�hero ts a conahuctian lending oyency for _ � � '� ibe performonce vf iha work fw which this permit Is issued � � , � � � ' ' ;. . -. .. . . (Sea 9097.Civ.C.). . . � . lendei s Neme � � � ILender's Add�su - � . . . �. . . � . ,. . . . . . , I terti/y iFro�1 have raad this applicotion and s�a�e tha�the � � � � � �� - �► - � �� � � - � � - � obove Intormotio�i:cwroa.I opree io comply with atl Couny � � ordinonces ond S�ate lows repula�inq Plumbiaq,and hereby � _ , , , , _ . . . , . . . . . -. .. ' authorize reprounto�ivea of this CouMy�o enter upon the � - � - � � obove•men/io�ad proparly fot impecfion purposes. � � - - SEE REVERSE FOR EXPUINATORY IAMOUA6E � �7 B? . qn uro ot Permittee . Date �. 1. .. � , � .F...t . ,�. . .. _,. , . ..7 . . ., . � i .'. .. . . .- _ R .,., . . , . „. � t. . , ., ,.. _. � Y . �. .� . . : , _..;� ;. �. t �' 1 :. .. ..v�..:. .. .. . .:....1. -. .. .. . .. . . . . : � . . . ._��,.:,; li_, �; 1�....�- �I ' . . . .� � � IPJSPECTOR'S fJOTES .... . .___. . -�, i , .. . . ' AF7POVA:S .. _ ^AT ,,., IhS,F ..:'S;IG^JATUc= . .I `..��,r.�� I cf.CJILDEk C � CF �I � _ . 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