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HomeMy WebLinkAbout1107A - WORKERS'COMGENSATIONDECLARATION pppl.ICATION FOR PLUMBING PERMIT ^ � I heroby,affirm thot I have a ceniHcofe of conaent to self 76A687A . � . ✓�� �. . inwre,o�a certifica�e of Worken'Compensotioe Insuronce, -CE 817(REV.8/88) , . . . ! . ... . . . ... I I . � or o cerfif�iayd.��wp�y tbm��of t.3800 lab.C.) � . . . . � ' . . U . P❑ol+cy N6(�L1�p. ompony '�./�U COUNTY OF l0S ANGELES �T 1��� OF BLIG.WORKS� Certifled topy is heroby fumisAed. � �� �d �l �� � � � . FOR AGRICANT TO FILL IN�PRINT OR TYPE) 8��� 3� ' � � , ..Cerrified copy ia filed with the couNy buildinp inapac- ADDR , lion deportmeM. . y/� - � NUMBER FIMURE OR ITEM � FEE ��L1TY , � + ,,, , � Dab�APPliSarfl' �/s4�J J - WATERCIOfiFT . . . Cp061 /7 I� (�'`J Lfl � � � ' CERTIFICATE OF EXEMPfION FROM WORKERS . � �� e%iH TUe . . .. � . � � � - COMVENSATION INSURANCE. � SHpwER ' : OwNER N � ' . _ " . IThlt�M�on nqd not b�compl�4d if fh1 work Ivolv�d hy ��t.. . . . ' � 1h�y�rmN Is!or on�hundnd dollan(ZI00)or l�ss.) UVATORY . D� qpppE55,. . � . I tertify�hot in the performance o1�he wo�k for�wMich this ,.�-�!J �JL � . permif is issued,1 sholi not employ any penon idapy monner SINK - Q� �itv vL��"/� � . ' 90`� ' �sa os fo 6ecome subject to tha Workers'Compeowiion lows. _ / - D�SHwaSHEa . a CONTRACT E � o Gr L/'L� � Da�e � ' ePPliconl CtOTHES WASHER � � A� x �y�b rJ . . � NOTICE TO AVPIICANT: If, oher making.lhis Certificate of �� � y��� � � �mption, you shouW become subject to the Worken' � SWIMM�NG POOI RECEPiOR provisiona of rhe Lobor Code, ou mus�forth- , CRv n,� �} j�E. . � �pe�sallon y LAWN$PRINKIFR SYS)EM I ' .ih comply with such provisions o+ �hia�permit shall be STATE 3 �K. G � �dasmed rovoked. -� � - '� � � WATER HEATER � ������ � �� - �� � � LlCENSED CONTRARORS DECLARATtON - � D15tRICE NO. VROCESSED BV � I hereby affirm lhat I om licenaed vnder provialoin of Chap�er 9 � GAS SVSTEM OUTlETS - ,`ry'�` � icommencing wi�h Sx/ion 700D)of Division 3 of Me Bosine�s „ WTtETSOVER ., . ,� ` ' d G�. �� and ProFessions Code,and m license ia in fuli force a�eHeU. 5 PFR SYSTEM FINAL r VALIDATION � ��'�� � : DATE � I 1 Qj U , ticenu Numbu lia Class � � O ��,��`�� �y ' FINAI � . Contrac or �6� ����7 BY . � �� ❑ I om eKempr under Sec. �. .. . - . . . . . , �. � i N B.BP.C.for this reoson Plan CF1etk fee ► .`"'� � O rI A Z Dore: p�UM81NG PERMIT ISSUING FEE S /p� :i' • " • • a Jr , ��Signature � . rotAt�e 1 • �9 4 5 0 � � Plan check applitant � � � � n s .,9(;,5�� ` SINCIE FAMIIY � HOME OWNER-BUILDER DECLARATION Nor�e ' . . . Q�2 7�II 7 � I�i1ereby affirm Ihar I am e.empt from Ihe Conhac+or'�license - A�reas � � - - - � � � - �� �- � -�-� � - � � � � �- � �for.ths following remoa(Secrion 7031.5,Busineu and � � �essiom Cods): Ciiy Tsl.No.� , ❑ I,as owner of fhe property,will do the work end the � �� afrucWre is no�inMnded w offered for saie(Section . . .. . . . . , . ., - .. . . � � . �, 7044,Busineu and Profeuions Code). � , � CONSTRIKTION LENDING AGENCY - �� �- '-- " - - -'� - � ' � - � - � � �� I hereby affi�m thm fhere is a eonsrrudlon lendiny ogency For '� � . �, the performonce of tM work for which thia permit it isaued � �� - � � . - � � - � (Set.3097,Civ.C.). - . . . Lender's Name ' ' � tender i Address � ', I certify that I have raod this application ond stafe that ihe . . . .... . - � .� � '� abare Informolion is corrxl.I ograa ro tomply wiih all CooMy � � . . , � ordinances ond Sia�e lows rapulotinp P�umbinq,ond heroby _ ' � „. � outhorize repreaenfa�ives o1 this Co�nty to enler upon iha � � ��� � � ��- � - � obove-menrfoned propeny for in�peclion pu�pases. � � � EEE REVERSE FOR EXPIANAiORY IANGUAGE � 8'�7-87 Sign�r�f Permdtee Date . .. -� . . . . �. . . . . .. .. . - . ,. ,_ , , , :. _ , , �-,, _ _. , :. , .. , , `, i., .... : ti. .�. �.. . .. � r, . ,' �:. .. : . il . ,. � . _ . �i c. i �'i i� ', , � ' ACFROV:.LS , ,.. ATE� � SPEC - 5$ICN.�TURE INS�ECTOR'S�OTE "- ' ' ' � ' -�GJ I FF T�UIIGFR�[ L �L��� _" ��UtiDER SCAB YJOFK ( � 'V #` � � � 1� 1` . . _ . . f .. ~ � � \ ].- • . � ROt1GH.FiUM51NG � �/�� �' � �� ..,�... _.. _ . Y�. ?i'S��1 [ri_.I.> >.�v r -on 71 c�l nnnc•c;-'s . ; -.- / .. � __ �_..� _. ..,_..._.....r...."' Gcen;� L fcr.ahc foqo ��n�r o.r.nk(Soctar 7i731 5. -- GASi'P,NG:. �� '�.� � �� � � . r :.. . ._ . GuslnesscndFrofo o .C det q ycirYo cc r���li�ch . .. . , r . _. � �, , � � C%.SVENi �.; � -. � t ,,. - -� ,_- •; � .....� , ,�.�. i - ��Yequiresa�:ennitfomrit'r�cfc��c �impro.E�demFih�,h. , . .'__ ._" . .--. <,.. �.. �. ti07 WF.TES H A7ER � � - � - -:� - -,� _ . � � � �- � 4'P � �Y slruclvrc p o 1 i �ssup�cc also rc _ , _ I ____ -__ t . � PIUMA t..;Fl%7U^[S 1 , • ..����, � �' � 1� ' -' �>'�.. - _ �"__ _�_ ... _. --_ �T_T_�•—��_—i� _.: .q �-es�lh� rr�fct f fo ach per n f f {iJe o gn d.sraM� � � ` -�' � � --� I -� ^ . �Ihol h IIc .dF�rsi t lo rh�p o s ons of�hc G:.STES� Z'; � \`. .�- . '.,-- �,'- �' ' - . -' --��--` Co I�ocfors U[en Low�(Ch pi 9..(ron'..�e dng w�rb UTIUiYLO.NOi�FlFD---� �- �--- - -._.' ... .�.�� ... _.�__� � �i, .; � ., SeclioR 7000J,of Dwn on 3 0(Ine Gusiness and Pro(ez� _. ' !� 11 i. ' . � . ..---... ..` � �� . ' i n��nd) rl�^�}ese�cii�flll --efr=on+aidthc�6ozis � s � \ �fc7 I � Inc a}7_g�d"�n pfon n y �blofo �/-Secfion FINAI .�``' '\�"\le`�iel���iui�_lrnrel � � :� - �_ -�� -_- �_�_ - : 1 70?!�5 6/eay�aPP!reonl for o��crmi(soLfbels fhc oppli� _.'_" .. . . .."_ . ',-_ .I',�_.-�-._ . � \.. --� -�- .. '". -- .� ---.� --, .�cc��;"�o,a n,�f pe dl},o(.np� o thnn iYc hundred i-�'=--�--'-• ;,'' _�� � � ��__ � dollars(5500.: � .. _ . _ . ��.. .,. 'ti'7USTFia...- . . .-� -.'�. _ __ .., - __ , �1�� I aso nz ofi.e�prope,t� �!Idoih rk �nd \A5T i1FFR0`lA � , �-• , , :__ .-_ ❑ � . _..... __ . .. . __ . � ,-, .i....i �..I..- .� } �Scr?�704r4rClsllc sci�Pro(sQo1nsC d� �Th Linfr � �,? r.•r ' � � �.; \� .;�. .- ._. -- -- -�--- . ei . S' ae- _'_ ' ____ . ,, _ i .i . for,s'<Iccns La.i,�Joc _nci rpFly lo ov�ox�ncr ol pr �ry . � �- ��__ . .� ....' . ..;... � ..�. . .: � . -, �:� i � ! . .. .• . .I I�,.w4a.Euilds o�im roves Ihereon. cnd who,dom th �� - ' .. .�� ., .�.�: I� � , �. i . .work hlmself p:ov ded fhol�such ImprovemFMs ere'no� �.......__. . .� . .._ . __.. ...... .. . ( _,. I ' � �`�---_� .! '-- -- ...--� -.- nfend.d o�a{/,?rnd(cr sals.�,Ir hoaever,:th�bui(d ng or --.' . —�l __ � ��. .. , i� I.__'_ J . �. _ '..._... .-�•___ _ . i -._y __: � � 'rnprov mcnt is,�ald wif}�in onc y. .ol,cnr;`Ic'w��rho ' '—'""-�� � --- � ---- -" - ,.�..:nwncr-h�7lderuii!(.ho ofF,r.f;�rdepoip;ovng.lhaih�d�d � (. ,.`;: i-.�� I �, . �....t_. '_-_- __'._'__"____._"_"__' '.� 'I. _._... �_ � nolbuildocimprovc/orfhop�cPo�seol-salr�. -i".t��; " _' �"_.._ I ' i �, ., � -. � � �� (_� . , , � ; ,' . \'•, n-. : . . 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