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HomeMy WebLinkAbout0691A (4) WORKERS-���N�,T�oNOE«A�,T�oN � qpp��CATION FOR PLUMBING PERMIT � � 1 he�eby,affirm Iha�1 Fwve o cenifieoro of conasnl to telf 78A887A � � insure,or�o cerfificaro of Workxs'Compensotion Iruuronca, CE 81T(REK 8/88) �� �:� . "' � � , ' or a cen�fied copy tbereof(Sec.380D,Lab.C.) , _ _ .. � . OtyNo.Q�$�ompcny S�R'� �U/)d COUNTY OF LOS AN(iEIES DEPT. OF PUBLIC WOA �? . CmNfled mpy is hereby fuml�hed.- - - �� � � �v� : �-� . . FOR APPLICANT TO FlLL iN(PRINT OR 1YpE� � BUIWING ;..� /1O - . Cenified copy is fikd wi�h fhe co�ny boild�np Inspsc• NUMBEa FlxtURE OR iT6M � FEE ��� ,� �ion departmenl. . � ioc,�urr � omes'�'$�1 Avauso�} ���+C�c�2 �1�m6,'.�q WATEACIOSET � r�esr - CERTIfICATE OF EXEMPTION FRpM WORKERS' O earH rue � cRoss sr. �tq �� ' COMPENSATION INSURANCE � OWNE4 �� . (Thls a�alon n��d�wr M eompbt�d if Ih�work involr�d by ��R , � 1h�p�.ml�b ter on�hund.rd dellan(SI00)o.bar.) uvAidrr ��t-. � � � � � . I AODRE55 (Q F � I cs•rify tha�in the performance of rhe work for which rhis SINK � GITY'C • � � 7 "�Y' S permii is iseued,I shall no�employ ony peno�in any manner � �'� �so as fo become subjed to�he Wo.keri Compenitttion Laws. - O�SHWASHER '' � � � CONTRAROR 1 S � . . . �� �^ ' ppplitanf � - CLOTHES WASHER , .JTICE��TO APPLICANT: if, ofte�mokiny 7hiy Cartiflcaia of SW�MMINGPpOlRECEPTOR A�RE55 , p Q S�. `E.emption, you should become aubject ro �he Workers' �Compemotion p�ovisions of fhs Labor Code,'yoo mVsi forfh• �qWN SPRINKLEG SYSTEM ��TM A � `3 ' �' ith comply with suth pov{aiern or this permit �hall be STq7E p�, .. . desmed revoked. ' - - . �� wATER HEArER p �����. n GA55 " � � ' IICENSED CONTRACTORS DECLARATION DISTRICT NO. DY � GAS SYSTEM OUTlETS �, 'I herohy affirm that I om{icemed onder provisione of CMprer 9 . O �'d m i (commencinp wi�h Secrion 7000)o{Div�aion 3 of tbe Business outlEiSOVER G � and Proieaions Code,ard my Iicense is In fu71 force and eRec�. � 5 PE SvS� � q Q (! ��/ �A EL y/��/�G� VALiDATiON v '. liceme Numbers7f 3�0•� �ic,Closs�� � � �' .. . . � ^ FINAt �, 0 � Conrracfor,�Ls�Date ri—�a—�7 BY �ol iv"'s U �. ❑ I om exempf under$va . . � � � '� 8.8P.C.for this�eoson � � Z � Plan check fae � Dale: , PIUMBING PERMIT ISSUING PEE 5 �. � � �Signafuro � TOiAI FEE ; . . � � � � Plan check aPPllcanl �� �+� SINGLE FAMILY . � HOME OWNER•BUILDEN DECLARA710N Nome� . . . :0 6 9,1 A � I heroby aHirm rhat I om exempr from ihs Controctols Lkense . Addro�s - � � � � -� - � ��r•� • • •$ low for.the follawinq remon(Saclion 7p31.5,8usineu and ' . �, Profsuioni Code): City Tal.No. - � � � � �Jr Q ❑ I,ac owner of the proper�y,will do�he work and the � ► � e ,� ,� fi�Q U skucrure ia not in�ended or offered for�ale(Section ._ . .. ., ,. . . .. . - . ' . . � � . 70s4.Butineu ond Profsaaiom Code). �, • � O�,� 4�8 7 � � CONSTRURION LENDING AGENCY �� �- � � � � � � � - - � � - -� I heroby offirm thol thero is a consfruction lendinq ogenty for � � � � ihe psrfo�mance of the woric fo.which Ibis permit Is iuued � � � - �� � � � � , � � � (Sec 3097.Civ.C.). ; . p� Lender's Nome � . . . . . . . . . . . . . . . .. . lende�'s Addreas - . � I certify tha�I hcva raad this opplicaiion and sWle thot Iha _. ,.. - . �, � .. _ . . , ' � � obove info�morion ia corrou.I oproe�o comply wirh all County �.. ordin es and State lows rogulo�ing Plumbinq,ond hereby . � � 'i oNh iz�r e�eNp� ss ol Ihis Counly to antar upon Iha - - � � � � �- � �. � � �- � - - 4 obov no pro ny for in�pection purpo�e�. SEE REVERSE fOR EXPIANATORY LANGUAGE � 3 jnoture of Perminee Dob � - � - �- � � - � ' �� - � - � L . .. - .. . ' . t..... \. .r4 .•.._..I . ,. . . . ..r 4 .,. ,T . I: � t^, . .,. '.L�. 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