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HomeMy WebLinkAbout1110A (5) • 4JORKERS'COMPENSATION DECLARATION APPUCATfON FOR�PLUMBING PERMIT /� I hera6y,oltirm Ihar f have o tm�itico�e of consent to sell �gpgg�q � , �'f I . . insure.or o cerlifiwie of Wwkms'Compensation Insurance, CE 817(REV.8/88� � � �� .. � - . . . . �� .. or o cerfified copy theraQo( Sec 3800,Lab.C.) . . . � ' - �� � � . POol�cy No.�`t�mpany �� F�� COUNTY OF LOS AN�EI.ES OEPT�-QF PUBUC iNIORKS Certified cvpy is he.eby fumished. - - � . / � ' FOR APVtIG4NT TO FILI IN(PRINt OR TYVE) BUIlOING '�j Certiiisd copy is filed with tha counly building inspec- '��� � f •� '� . li deporfinenl. NUMBER FIXTUREORI7EM � fEE �j9((��`�1�.�2, tocntm Dote�L�il�AppliSonr� .P � �- WATFRCLOSET- OD �Q�� . . CERTiFICATE OF EXEM�TION FROM WORKERS' B�iH Tue � - ��ST• _ -�- COM7EMSATION INSURANCE SHOWER ��R ' � � � - (Thi�s�Nbn n��d nof b�complrt�d II th�work Involv�d br D �i . . .. .. . , - th�pumM ii fOr on�bvndf�d d0�larf(SI00)Or I�ts.) �qyqJpqV �R�35 . , . I ceriify Ihot in the performance of the wo'k for which ihis _ • permir is iuued.I shall not empioy any persoa in any manner `'�NK � C�TY 9��,., � ' so as io become subject to tha Workeri Compenwtion Lows. � � � , �DISNWASHER CON7RACTOR . P Date erpli[ont CLOT1iF5WA5NER � � - - � NOTICE TO AVRICANT: If, af�er makieq this Cartificote of ADDREss R � , .. " � �J^mpiion,youu should become subjeU to the Workers' `��'������CEPTOR CITY�� � - -�O � ipensofion pro��sions of fhe Labor Code,you muaf torth• �qWN SPRiNKLER SYSTEM ' w�fi tomply wifh such provisions o� this permit sholl be SUIE L ' ' �deemed revoked. �� � WATER HEATER ������ 0 C1A55 �� LICENSED CONTRACTORS OKLARATION � WSiR�CT NO.� VROC455Ep 8Y I hereby offirm thpt I am Ikenxd under povis�oos of Chop�er 9 GAS SvSiEM WTtETS � (� � ' (commencmg wi�h Sectron 7000J of Oivision 3 of the Business .. pUTIETS OVER . . . . ' Q`� > � ood Fo{euiona Code,ond my license is In{uil force and eHxt. 5 veR SYSiE/a FINAI � �,3��� VALIDA7ION O r� DATE l/ �f'!_� V j License Number �!J��� Lic,Closa �3� ' � � � ,� '7/ Q� FINAI /�!•�, � � � Controctor bateSl� � . BY %/�i�""`�` V ❑ I am exempi unde�Sec. � - , ; � f 8.8P.C.for Ihin reoaon � :�� � �.O A 2 Plan check fee Dafe: PLUMBING PERMIT ISSUING FEE 3 �� • • • • •5 Signofure G � TOTAL FEE - D ' � I • � � A rJ(1 , - . .. . - . . . � Plon check appliwnt � . . � 9 1 1 £i 5 L'u SINGLE FAMIIY .. . . . � � , HOME OWNER-BUILDER OECLARATION Naroe � � � � �g 2 7_g 7 j�rreby offirm that 1 am axemp�from ihs Connoctoi s Uwnae .� Addross - � - � � - �� � - - -- � � - �� ' ;for Jhe following reoson(Ssction 7p31.5,Bu�ineu and � res:ions Code): . Ciy Tel.No. �, ❑ I,os owner of fhe property,will do the work and ihe � ► � � � s��uUuro i�nm totended or offe�ed fw nale.{Section -.. . . . � _ . . . . . 70u,Bu�ineu and Profemioro Code). � � CONSTRUCflON LENDING AGENCY � ��� � � � - -. � � � �. � � � I hereby offirm tho�ihe�e h a comhudion lending ogancy for , � . �he performonce of the woh for whlch this psrmit is issued � � - � . �� � � - ' � - � ' (Sac.J097,Civ.C.). . ' Lendei�Name � , �� Lendei s Add�eas . . . � . .. . � . . . I certify tFrot I hovs reod this opplication ond sWre tbot Ihe �.. . . � . ► � � . . . - . . t obo�e infama�ion ie curect.I ep�ee�o comply wi�h oll County � ordirroncee and Sble laws requlalinq Plumbinq,aad hereby , , _ . _ . _ _ . _ . , _ _ o�rhorize reprasenbtives of/bis Cou��y to enfer upon the � obove•meMio�ed proper�y frn In�peciion pwposea. . . j SEB REVERSE FOR EXPLANAiORY LANGUAGE � � Q-�-�Y��.�' f1 a7-87 Siqnmuro of Permi� e Ome . . . . ... . ... .. �{ i t- . . . ,°A .,� . '4 ''r '�'r� G - .f �. , . .- �.. .:_ ... . . ' . : . . .. �:�: ,.�, . s. � , ��1: . . . . . o -. 1 . , . . �� , . ..�i J A�fFO'✓h:5 DA7E „ IN'_PE OR'S$iGNATUG= ' INSPECTOR'SNOTES ' '- � ' ' '0J " '- 'i0 f eF-fsUILD 'D=CL.vRA �iLf� -' � _ � - UP.'CERSL4�JV:OFK . �J//�dy'�� .:.,� � Yi!' � ._`,�.�Jhc��l�n � hoil� �np�10 I'�i,C' c ,' . 1t d-t ' ' �.�.ROUGHFitll.'A,:.G..___. _L Oy.-. '� '...'. . ....�... ....�.`�. _..� .._.. ___ .._Y._._..._. -1 s. L �m fc � o fnllo n9 rco �Se l�0 03)5. :. GAS CI7 N� �' ` ' � � � �-� R srnoss c.,1 P ! ssions(.ode Any c�ly or coi�nr�z,.��cti � � • i .. • � � . � '. � ... ..�._, •.�. .• . : • --^--`-=' . . . ', .., i I ..�. ' ' requir e pC nii ib'construcL'clra j raic.'d mali:h. . _. =_�.� .-,--��__ s r c GAS VEI�i � � ; 4 •. . . . � , • .- . f___ .. _.__:.._. _.... ._.__.-.�� ._.._. . _.."' " P epair On�Sf��Clu� �fior fe I15 SSl'�nGG. aii��f HO7wATE:HEA7FA ._-'..:e�i-•. _. •:: a• '...l--' .�i; ., � . ,-"— - •�.q}Irslhe-a{»trcan!fo�•vchpe�miYtoficdslqned.storr PLUMB:�JGFI%TUR ;�� ( f�. ', t':. "'. ,' .. '--. . .�-.. ."" .._��. . . � .._. - flhalf !t� sed� �c�f l 1h r i5i �s flhc S 7EST �'�._-...2'��..��y� � �..��' �... . _ - _.-___ . . ..._. . - -.. �� rl o�ro�'i Lcc f td (Ch Pr,.r 9(m :..en I g �!h GA , � -"'T b ,-r�-��J ��,,. ; I _;.. !� Seclron 7CCG)ol�D 'is"n 7 01 fbe s� n ss ond Profes- unurrra_r.o:u�.o -- .-- —_ _ _. _._.�. _ . C !h t - � .h � �h �b, . _._. _._�-._ .._ ,.__.'_ __..___._... ___. 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