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HomeMy WebLinkAbout1108A (5) WORKERS'COMVENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT � � I heroby,offirm �hat I have a certifica�e of consant�o self 78A887A . . insure,or a cerlifimte of Worken'Compeosolion Insuronce, � CE 817�REV.8/B9) � � - . - � � �� ��� -- � � or a ter�lfled copy�herao ($pc.3800,Lob.C.j (^ _ . __ . . - �' _ . . :. �-� � .. . . ' J S.4A.�,e � COUN7Y OF LOS ANC9E�ES + EPT.OF. PUBUC WORKS � P❑olityNo.�� ompony S-Q . � . - 3 �S.- / . . . _� �Certified cOpy Is beroby furnished. 4 f�� � .� � . : � - � FOR APPLICANT TO Flll IN(oRINT OR TYPEJ BU0.DING� .�1 ' `� Cenified wpy is fiied with the couNy boilding inapea ADDRESS Io� . /ti�on daportmenL . . NUMBER fIXTURE OR ITEM ���TY � FEE ;q m o b � Date`�'����App�iSO�t �sehe wnr�aaos�r - . . 00 NEAREST ' ' 1 - �' . CERTIFICATE OF EIfEMPTIOM FROM WORKERS' - p� BnTH TU6 . . O CGOSS ST. 1 V � ., � COMPENSATION INSURANCE-� � ^ OWNER -�� - . " � - . (Th�s s�Nion nwd nof b�compl�hd 11 th�work inrolv�d b� � d+� SHOwEre �� ' n�,oit th�p��mH Is for on�hundr�d dollan({100)or bss.) tavqiORv � qpp�u I cerilFy rhot in�ha performance of the work fw which Ihis permit is iasued,I shall not employ any penoa In ony mooner ry SINK - � �IiV" � � . ��-q(p"1 qs(,� , � so as�o become wbjact to the Workeri Compenso�ion laws. O�SHWnSriER ' � ��AR� � c p potx Appliconl � '� CLOTHES WASHER � - ApDRE55 � . NOTICE TO APPLICANT: If, ofter moking this Ce�lifico�e of SwIMMwGP00lRECEMOR f�rnption, you shou4d become subject ta ihe Workari ��Ty �penso�ion provi5io�5 Of ihe labor Code,yOV musl forih- �AWN SPRINKIER SYSTEM Pn �� � .i0 comply wi�h soth provisions or this permit sholl 6e STATE 7 UG . '� deemed revoked. ' � � �' ' WATER IiEATER n� LICENSE NO. J C1A55 � IICEN5E0 CONTRACTORS DKIARATION � � D�STR�CT NO. . PROCESSED BY GAS SVSTEM OUTLETS �I heroby offirm thot I am licensed under provisions of Chapter 9 O Q , rn � �commencinp wiih$eclioe 7000)of Division 3 of the Business . . OUitETSOVER a p� � ond Profeuions Cade,ond my licanas ia ln full force and effxt 5 PER SvSiEM FINAI VAUDATION O 3\3083 C3 ' oAr� � ;-%'�v c� Licenx Number lia Closs� FINAL a a Conlractor 1� �e •Dote�� . BY �/�L'SY2<�'�� � ❑ Q I am exempt unde�Set. � a C7 8.8P.C.for this reason � Plpn CF1CCk f9e , � � ="•1 1 0.8 A ' r DOfe' � . PIUMBING PERMIT ISSUING FEE Z O � �i° • • • •S � S�gnature . TOTAI FEE s' ' ' � • � � Fi.J�� . . .. . . . . . . .. Plon check appllcom • �� � � �5 n c�i � 5lNGLE FAMILY � HOME OWNER•BUIL�ER DKIARATION Name � �-0�.2 7'-S 7 � lhpreby aHirm that I om eKempt from�he Contractor's license - qddro»� � � � ' -- ' " � - �� ' - � , T ��for dhe foilowinq reoson(Section 7031.3, Busineu and �esaions Code�: - City Tel.No. . . . . . ❑ I,as owner of ihe propeny,will do ths work o�d the ' atruduro is nor in�anded or offerod(or wis(Section - - � ► � - '. - 7044,Bvsineu and Professiom Code�. � _ CONSTRUCTION LENDING AGENCY � ��� " " � � � . - � �. . � . � I here6y aNirm that ihero Is o conshuction lendinq nqsncy fw � . � ' . � the perforrtqnte of Ibe work for whith ihis permil fs Issued � �� - � � �� � � ' � �- - � � (Sec.3097.Civ.C.). ' Lender's Nome . . Ltrnder's Address - � � I certify that I hovs reod this applica�ion ond stote�hat rhe - � � - �- � - � � , -- � - � - �- cbovs informotioo is conact.I ogree to compiy wilh all Counly " . wdinances ond S�a1e laws reyulplinq Plumbinq,and hereby � . ,, , , . , , _ _ .. � . � . ., . . . . . , outhoriza repreaentatives of thia County ro eMer upon�he � • , obove-me��ioned poperly for inapenion porpo�ei. � � , SEE REVERSE FOR EXPLANATORY LANGUAGE ' �_�-��Qf �3 a'��� Sipnoture of Perminee Daie ', L � „ , __ r. • ts ,•� . ;.' � . , ,, -n � , ,. � ,,. �, 1 , . t ..6 t.� , , .. �. . � ..r .... . �..... ..: ..� : ..'.. u. . . . . � .. . . . . , . . ..... . .. ���: C.. . . . � � .i . . i '�� ROUGHFLU�OVAlS CAT �,.. 115r_ �R'� JATURE .. .. . . � . . . '. �(FUI C! ✓I,lt l��iF i�'1 ' qpp M�?ECTOR 5 NOTES �. .. UNOEh S.AB V�ORK ,,=- ) e!'l`� �---- . . -' ' . t, . i : . � . . . . . � ' � J P-1--1.i- � � ^ yf:�,�(1, � c -� . . '.:Clt: _ .��.�/� .,1^'�V-� � .._..,_..._ ._ c ,1Ft Gr� �C<� i 1 l� I m i �fi_o�.T -�.._.. _-.-'---^ -.. ...-.- ..-_- L censc L for t.q Fa q f a oo ;Secf� 1071 5. .GASPiP�.NG �l �-. � � _ ' r��... . . ,.��7-..�. .. .. � _ �.� Aus�nesscndProlessonsCndc! A + oree nl .._'_f '.,y..,�\'_.., � �;,. . . '.r” � YCY /.�.Ii:ch GAS\�h.7 . .. � �ti F — �� � ,� , I ...,� - -. '.r q..�rr��s� F 'mif fo�ronsfrucl.�-aiMc 'i.Fr�v .c�cmof�sh. ��O'WA7EFH:A7ER_._-_ ��. .. '�.'._.,�.� �,- ���--'�-"-'-- '-�' - -._'.. ` .�-' � i or repair a�y siru:t�rc. priar,jo }s' s.u^n e. olso rc- FLU.N6't:G FIxiU2„,J;' ' .�-�. ! . . " y,. '- - .-- ..._._ ..'_. � < •_ I �'��qV r p fhcupp�conl I v h pern 1Y �Hlo. s 9.� 1..rore� -=1 � i . rlhofF Icenz dp onrl �h� p ov o al��hc . , �-, i _� �_ ° �r t GASTE.i ._z ��� � ,__ - S. ..i= . .__._ �' . .--�- � Coni�o;rors[ccnsr Lo�(Chc,�r 9(commencin wi�h j 9 U7iLITYC0..�1�IIF1.�_'_._�_ ._.. I_ _ __, _�•_ 1"I , I-�_-"� ... � ...- �1 Sechsn 70001 o/'ONislon 3 o!'fhe'Buvness and Proles- _. f ..-_.. .. ._"�. - __, ' . .__ ' ___'... ___. -_:_ � l � (lo i'co cll�r�rl����'c lpcohmpltYcre�oi�urtd�FS bf on HNn[ �.li"�� .��I'rsf�r,an �rnn( V , ,I,� , �: :',� t ' 7031 3'6y any Gpplicc I fur a�perm�I,�sLb�eci the oppl�� � . � i�..'_— . ; . _. -. . . - . ." .. - - -- - - ' t,tv a eivit.pena(fy / �ol mo '�hen 1 ,f undred �N�usTc.n: -- .. ... . . 1� � .�—�—_ . . dolt6�'s(SscoJ.:. , .. _ .� ., . .. '.�' �'� .' ._ .----- . . _ ..-- PIAS7E j�vpKpvq� �� - "���� ---'� .� .. .�- . — � �_,_ I � ❑1,as o�.vner o th ope�t�v:ill do tFe v.a k.ond � ` �� ..( � :-. . � � i. .."�._"_I _ ____ . .__'. ._- .�,_...�ynr,strvcto �snotinlcnded1cr�ofi �dfcr-.^.I .. r - , , ._, "- ___- F , , . � __ - ---- :r r �- , � .,y � , --- ------ ., (Sc�.�704� Cu ncsiondProes� nsC a . '-7hc o Irc _ I . idr's�Lironso Cu ,does nol cpply fo n o c�of p(�'^�y � � � ��,�� who 6vtld 'o improve 1herGn o d �ho doc �ch �.__.__ _ _....., .,�_.;.�\ � ��� ,�\ �.� � .. , � i ork hfmsclf proWdad t��ot such Improvemen/s crc nof " � �-. .� -y� � ' �:•.... . , -��- � - -- - - �•-- - /en:iod.oro lcrad lo ofe-fl, o�vcve:.�the 6ui dmg or . � �.� _ ' � - -. __. . .. .. _ � � ; .� ,'' I , �—_', �� ____,___ :.�. . ._ .roprovcnentffs snf�vi.1h q onchYeor ol complht/oa.!hc r � � - :':�� - � . ovmcr-6urldcrv:illhovnfhcburd nolp;ovinc�f clh�did ..., .__ . . _ ..._"'_' _"____"._„__". �- i'� ..:3..1' . I - 't--- --- -F--- '------------' � �� ' .._ � �.•::.nol bvifd cr 1 np�ove.lor.iha purpoee ef s:lc I �. . _ -'----_.._.. i . , i � .� �---i ' � - r ----- --. . -"- -J----- - . _ _• :_ _.. _.� -- ; / ` .. . . - � � � ' �_ � � ---� �t�i,mJexemptunder5e�. -- .� . 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