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HomeMy WebLinkAbout1104A (5) , WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT ^✓�� � I hereby,affirm lhal I hove a cerlifimte oF consenl to self 7BABB7A -� I I inwre,or o certi4icote of Wwkers'Compensotion losurante,� CE 877(pEV.8/88) , � ' � � � � � - �--� � �U'-��� - .. • or a cenified capy ihenoi}� 980 Lab.C.) . - .. . ' � . � � . . �cy No. S3 �D�,��ys��/�� COUNTY OF lOS ANGELES OER'f:OF�P BLIC,W.O S Cenifled copy is her by f�mished. ' �� ���� �,/� .y� ��. - - � � � FOR APPIICANT TO Fllt IN(PRINT OR TYPE) gADDREu f`^►��.(�/�' . Ceniiied copy is filed wi�h the roumy building inspet- � � �+ion d�ep�art�mye-n�t , NUMBER FIMURF OR ITEM � FEE ���m, , po�e �SLDJ_n�i�to�� �SC1�e 3 wnr�Raoser OQ NEAREST l f� !'�D /a� CERTIFICATE OF EXEMVTION fROM WORKERS' . p �- BArM TUB � . O Cc065 SL 1 . ;, � COMPENSATION INSURANCE � � SHOWER OWNER �'I��� ' . ..-. . . , (Thl���efbn n��d not b�tompl�Hd I(th�work inwlwd by ��i . . . . . -. ' . M�permif M for on�hundnd dollan(5100)or In�J 5 UVA70RY - � ,�,ppg� , I certify Ihot in the pmformance of ihe wo�k for which this � . permit is issued,I shall nol employ ony person in ony mpnner SINK CIN eO� � _ SO 7 � so os fo 6etome sobject to fhe Worksrs'Compeosotion Laws. - DISMWASHER � � . . . . . � . . CONTAACtOR � � � � Dale e�lifonl �'� CLOTNESWASHER (� C� . NOTICE TO APPLICANT: If, aher making ihis Certificata of A��� ��� ��� U An -' " - � �.�mption, you should become subject to the Workxs' . SWiAwun�GP�OLRKEVTOR Grv i �ipensofion provis�ona of the Labor Code,you must forlh- �qWN SPRINKLEH SYSTEM A n 3 �� ' .n fompfy with such provisioas or ihis permil �holl be STA7E Q`� lIC' C 3 ��deemed revoked. ' - � -' WAlER HEATER ���N��� ��0 C1v C1A55 �� �� � LICENSED CONTRACfORS DECLARATION � � . . .. D�STkiCT NO. PROCESSED BY �. I hereby offirm thot I om licansed under povisions o/Chapler 9� � GAS SYSTEM OUilETS 1 (commenting wiih Se[tion 7000)of Divisio�3 of ihe Busineab . . pUTlET50vER . . . � Q1 d G y � ond Professions Code,-a�my licen�e is in f�l I force ond effxt 5 PFR SYSTEM fINAI. � ` C ' DATE �/�C �,f,� VALIDATION v license N�mber �L��� Lia Clau� � ' Contractor .. . .Dote v—���� BIYAt `��'a��� F I V '�� � ❑ 1 am e.empt under Set. � " , =, .� U,4� 6� ,� B.BP.C.for this reoson , �• o • • •5 Z Plan check fee �� Dole: p�UM61NG PERMIT ISSUING FEE S . 1D �� � � I ^ � � �J O I Siqnoruro � I TOTAL FEE , � • � 11E.50� � � 71a�cbeck applicanl � � �� SINGIE FAMIIY . . - . O�2 7�8 7 � HOME OWNER•BUItDER DECLARATION Name � � � -- - -� � ; I hereby affirm thot I am exempt from fhe Cvnlractor i license . �d�� . . . . .. .. . ; . -,, � . '.�.-. � . . . _ _ . . �, �•for.the following reaso�(Sec�ion 7031.5,Bu�7nesa ond i ! essions Code): Cily Tsl.No. , . _ _. .._ .. ��, ❑ I,os owner of ths property,.will do iha work and the . - , struc�ure is no�inlanded w oHered for wle(Sxlio� � - � � � - - � , . � �� � -� '�, 704I,Bua(neu orrd Profmsiom Code). . . , '� CONSTRUC?ION LENDING AGENCY � � � - � � . � � � - � � � 1 hereby affirm�het thara is a conatruction lendiog aqenty for . ' . ', the pe�formance of the work for which fhis permir is faued - � - �; ��� �� ��- � (Sec.3097,Civ.C.). .. , � Leader i Nome . - � � �� Lendar's Addraas . . . . . . � . . ' I te�lify Ihot I hove read this opplicaiion ard alote thnt the � �- � - �► - . � , a6ove Informo�ion is cwroct I apree�o comply wifh oll Coonty , : ordinonces ond S�a�e bwa ropula�inq Plumbinq,ond heroby . . .... .. . . - . � � , � � � - � '� ourhoNza repreaenro�ivea of lhis Counly�o enror upon the . '� ,� above-mentioned properly fa inspeNion purpose�. � � ^ ' �i� � SEE REVERSE FOR EXPLANATORY LANGUAGE ����y �o�7 8 r�� 1 ' Siqnoture of Permihea Dote � . � , . . ... . v , 1' F R . �. .1" r' ...,T ....'!,.'I7!. - . � � . L:i ...a.. .. � . . ..... u .. .. Y. _. � 1 . �w � Y . .�. . .. r. i ._ , i_. ... ' ne�aovc..s �,T�� ._ir�svF oF v^iu e' :.�_S._....�._...'1�...`_.4.'_INSP6C OR'S t OiEo . . ...� ` . . � �J'c4°`I G F.Ct [ R�. �h) Co rcr . ,� ' Uf.D�R SLAB WORK �' l.// �_ � ��/ I �, .1 I F r " ROUGHPLU'.'� � . .... (/Op_ . .. ._._ _... " l h�.s a (G thG f II f- -t l � S Cfyn h�3�I}'. ,. '`,_� ...' .. :,�., .,�,�..;�.�,�: ... _ . "' . L GASV'�N^ ... . .. .., . �.7''i�.�,�,��__"'_' � .. ` P . or9rc a( s . C d A � ��yo co nty�vi2L<h �t �.`, .�oa t., � � � --t e m� dr� . �- C -. . - -. ..�. � . ' fC50^�l`t�11 Y�UCI �fAf' F� C� t�i�:h. — �..., . _�__'. .._. _ . _. �_.._. _ . . po�r y structu pno to R�°ssua cc,.also re- HOTWAT�BHFAi',2 —_ ._._... ..=_'__ ._ _..�._ � .. � r ,_ . `_ � � . � ' � � q�lres Iharlr+��.cnNo /ch,per�uf !rlaos qn d �a�e- FLUf1,B��;G FI}'TLF G.'� n'�• .��f'� ;r .' . �-' � � --. . ..... - -" -- ' ' .ni Ih I F i�-c s d(�u Suo f lo fne p o �z- nt o(1h� G.�STES' � -/�'f-� (�,1. i! '. -'.._. __',�.... . . "._ ...__ - ._ Controci ;s C rcr Lov(Ch 4.r S(con encing wifh �_ ( "'` ' _ '.,_.' ' uTNiv,Co.slor�s.co _- --- ..-_ --'- , . �-__'_ _... .--- ---�� rdnrlaalfe�coJ�c,�cn4 ironm`F'''nhE�colo/onnodFsi6�es . . .- j. _. .._� ._� .�, 'y . ' � _. � ' ..�.__.. .._ � C� ' .. . ' y ^ n I on Final ,.,,.. t . �` ' ' i ; . � ; 7031.5 6j ony a�ipl. t lo..c{� � i sub�ccrs�ihc cppli� �. _ � ' _'�.�'�."_,.-1� .:__� . �..;_L� ,..�'.—. �___ ' _ �_ � i1o11fa�Isa�s�e.v�crcftlhef,nor mo I�io f v .hun8red .. .F' ��r n r il � � . _ _ � .' _ � � _� . �.r. . . . 'N'JUST[7.4. .._• .1 � . . .___ .. _'__'._. ' o rt v-I do Ih V.ASTEy�C:�pJA. � �. .. ,! . � — —.— ."---�•— Y e � f � , . . -� • ;'•� ..... . ..�. � .. . � r -- -t�e strvc�ur�-ix rr_nt!rdf er offercdlfe a��rw o.k,and ..'�- '��---� -._`.- --- -- . .... . - -- --- ^.. �� . . ^'-:� .:_.•.�'.�---=-�-- ..-�---- �- �'. i �_ : ,. ., . .. ,. , .,' - -! ` �(Sec.704:.6uslness andF;afessionz Cade.�ihe Conlrao - <•. . . . r r -..'1 ;___.� ..___ `. _..,._. . .._-' _ .. .—._ __1____.._.. .! :�to�r's2RensoCcv✓d esnoicprfy/ ..ow e orpr�^-fy t "�-- -- - �� � � �� ' . i � 1 �.who Lwlds�or{mp oves.lfiereo� �nd�'.,ho doe, :b c _ '- �� : ..i, � I i� : �.�, , � �work himsel/proNded that su h tmp�orcrricnls,crc no� �.,_... ...__ "__,_ .___._..- .',J:,_ . ..,.� . , � __:.-._),__. iNendedo�o(lr.red(or:scle.:!!,'�owcver.�f6ebuildingor •_...... . .. ,� �_ ..., .._ .._. . .._'_' _.__ . . . � '• �j� i ; . r.�.� _._� � ! _,impro ement's snfd vdffain one ycar ol,camplei;on.,�he ' �.' � „ �. I� :. . -.. . 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