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HomeMy WebLinkAbout1111A (5) • WORKERS'COMPENSATION DKLARATION APPLICATI4N FQR PLUMBING.PERMIT 1 hereby,affirm Iha�I hove a ce.tifiwte of consenl�o self ��g�g�� � . insoro,or a certiHwro of Wo�kers'CompenwUon Imuronce, -�CE B77(REV.B/88) . .. . ��. . ._ . . . -.. o�a certified co�S�c.3800,Lab.C.) . . � - . -f•i <1� F�n� COUNTY OF LOS ANaELES DEP7. �!R PUBLIC WO�ICS O�Y No. cs ao�y c�i (2 S-� Cerirfisd copy is heroby fumBhed. BUttqNG /+ � . . FOR A�IICANT TO Nll IN(�INT OR ttGEI qppRE55 �� �� �o O ' ; Ceriifled copy is N{ed with tbe munly buildiny Inapec- ti n deporlme�r. , NUM6ER FI%TURE OR ITEM Q fEt t��n,.. WA7FR CL06Et � Do�s` � Appiie�,on� . . NEAREST . . . � . CERTIfICATE pF,E%EMPf10N FROM WORKERS' �'n+T�e � a�O ���' � . . . . COMPENSATION INSURANCE . OwtrER . - . � (This a�dion nNd not b�complN�d N�h�work In.olwd 6� ��R C th�p�rmif b!oe on�hundr�d dotlan({100)o.l�ss.) IAVATORV '��t rao�ss -I cerffy�hot in rAe perfamanro of Ihe work for which ihis . �,permit is issued,I aholl not employ ony person In any.manner 5� ��rv � +q�p �o os�o become wbject to the Workeri Compensaiion Laws. D13NWASNER ' Coratrtwcroa I � � � Dole ' eryliconl � . � . CLO�NESWASHER . C ' . NOTICE TO AVPIICANT: If, aAer making this Certificole of ��� �� ' fy+mption, yoo �hould betome wbjeU to the Workers' � SW����'������ ' ipensa�ion provisforn of�he Labor Code,yoJmuo+fonh- UWniSVRMIKtER9V57EM ��Ty � df� o� . ..nh comply with such provisiona or fhid permit ahall be STATE tIC. ���deemed ravo4ed. � � � � . WATER MEATER - ����� �u � . � � LICENSED CONTRACTORS DECLARATION � DiSTRICT NO. PROCESSED BV GAS SY51FM � OUTLETS I hereby affirm thot I om Iicenaed u�der povinior»of Chap�er 9 (}b . -(commencinq wi+h$ection 7000)of Division 3 of iFie Bufinefs OU7LET30VER . . 0 �G' O ��. and Profeaaiona Code,ond my license is in full force and effec�. - S oER SVStEM � FINAL � �.// VALIDATION V � ticense Number ���3��� Lic.Closs �3� DAh �f� 3/a� O i FINAL i: ConhoUor i P •Dote �D'g� . BY ��„'"`� W ! ❑ I am exemp�under Sec. � . . a R1 ; _ B.BP.C.40�Jhis reoson plon cheek fea � � � � � z i oaro: ��1 1 1,1 A CLUMBING PERMIT ISSUING FEE S Q O � Signaluro $:• • • • e 5 � TOTAL FEE � i � - � Plan eheck opplicant . � � ( ° 1 � �'�� � SINGLE FAMILY � •• 1 1 8 5 Q� HOME OWNER-BUIIDER DECIARATION Nome � � ' �.henby offirm�ha�1 am exampt from the Connacror i Ucanss . ,qddraos - � �� ��� � �D H,Z 7"�7 � - ,for�the followioq reeaon(Sec�ion 7031.5,Busines and � � � (esstons CodeJ: City Tel.Na . ' ❑ I,os owner of th�propeny,wlli do the work ond the � � i � a��ucture is not Intended w offered fo�aale (Section .. .. - - � ► � � �� - � �. 7W4,Bu�iness ond Frofeasio�a Code). � � � ` CONSTRUCTION lENO1NG AGENCY � � ' ' - � - �-- �� � � - � � � - � . �� ' � ' �- � � I heroby offirm thm thsre Is o conanuc�ion Isndinp aqancy for � � Ihe performonce of ths wo�k ior wh7ch Ihls permit is luued � - � � � � � � � � � - (Sec.3097,Civ.C.). . � Lender'�Nom� . . . . . . . . .. . Lende��Addraas - �� � I cenify fhot I hove raod�hia application o�d state that the . . . ._. . . . . . � � .. , obove Infwmmion is conect.I apree ro compiy wirh all Couny , � � ', ordirtonces ond State Iqws requlo�iaq Plumbinq,and heraby . , ._ _ ,_ . . .. . I ouihorize ropreseMotives of this Couny ro emer upoa�he _. � abo�e-memioned properry for irnpec�ion purposes. SEE REVERSE FOR EXPLANATOHY UINGUAGE � �� '.�2'��� g.�'I-R� � SiqnoNre of Permittes Dole � '1'... . . . _. . . .. . � �_ .� . .�. .. . _ . ;i,, _ , . n, ,.,{ i . .J`SI'F�TOR'SS1G'.ATU�E ' INSP:CT02'Sf�OTES �..�.. : '. ,.;>.• .°1-�n. -,0��h��n-E�UI Cck.Ci!.l�Pt i�l'j.. ' .�. � nrot+OVq.S .,. . DAiE r . . . � :� U�DERSlA6540RK ~�+� �'.jt! J . �` ,• �� �L• . _`���} U� �� , ¢..�.1 i .�I .�h�.�Ct� : rf67 P � COUG CiUM11PIN('- . ' �j�`' . 7 ....._.._ .__. ._.._........,._,�_., � ( l Fl �L fL S`j . . �--! - - "-' "- � L<c s lr I� ',c,fol o -t q {Sn t� 7031 5. :� G�5 vlv n,G � � -.'�. :1 � . �, . � . ' � ' -. .. - B n I!o! n C de; Any uy or ro:� ��-w!i�ch .., .-, '_. - ., :.�� i � . ..�, . , , . .- GASVFI.7 . � . - . �. � . � ..'.r q csopc� ,�F o�vt1[��I.ah : mp.a d.,� ��.h i 1- ep � a y 7 I p t �rl ss � � ols HO'VJFIE:NEAiFR . ___. .'' .. . -_ � -----1 . -'- . -... ... - re� �� y i ;� i � � ;�q 3ce fhei �a fl r vrhpcl �i7 F� o�edsfarr �IUVBIt�GFIxTlI�ES ;, � � �' - . .. . i- .��_. �-._�_ .. -- - - rIh rh 1�ensedP nrlorh Povsionsolrh� GtiSTESi . �C'L� � , I �-� , -�- - -� - � Co r cci �'s Sicc s Ln�fLh o/�.r 9(com�nrnc 9 �rF, j' U'ILI.'Y,'f_O.�hOFIFiFD----- - ---- ----��-^-- •- -- ' � _ _. Sec1lon 7 0 oi 4 o J I I}c C srness nd Prol s� , � I 0 / s o u ❑ r. .. _ .._'.'.` --.. ' ' - ' -- � ' nsCud�; that� .�]o cr�,pr lh� �cn�a d th�6c� � � ' � ' ' . �7or �he o71 q I . .�ri�pbon Fny loiinn o! SccUan ( c'7 �-_. ., �__ _ .'_,. ._'_ . 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