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HomeMy WebLinkAbout0930A (5) 'N°RKERS•�°"^�"�T'°"°E«"R"T'°" APPLICATION FQR PLUMBING PERMIT ///777 I hen6y,affirm�har I Mve a ceniticote of conseni to self 78A887A � ' _ , ._ _ __ , . . � . � insure,or a tenificate of Worken'Compemation Inauronce, CE Bi 7(REV.B/88) , . � . , _� � '� .. .. . . . .. .._. .. . . or o certified top ihereof�5ec.380D Lab.C.) . � . - " ' � � � al� (^ / COUNTV OF LOS AN�ELES DEPT. OF PUBUC WOR P❑olity No.��Company�7�e /'V/•�/ . . - �' '�jl 3 � Ce��ified copy B heie6y furni�hed. _ ` � iOR ACPIIGNT TO Flll IN(PItiNT OR TYPE) �� BVILDING r� C �,/�I Ceriified�opy is filed wi�h rhe couniy buiiding inapec• �DDRE55 ��] .�G• �O` Pd tion deportment. � � NVMBER �FIXfURE OR ITEM � FEE �' ��,���7 LOGIITY. ` . _ . . Oa�e�Appliqont � �� �- 3� WA�«�T. . . . . o NEAREST. -� ' CERT�FICATE OF EICEMPTION FROM WORKERS'_ � a. &4tH T�e _ OD ��S�T� .- _ COMPENSATION INSURANCE � 51qWER- `a� �ER Q . . . . � �� . . .... � (Thb s�crion nNd nef M eompl�t�d H fh�work Imrolwd by .. . ._ . _ }h�p�rm�T L(or on�hundnd dollao(SIDO)or bu.) � IAVaTORv �n . . . ADDRESS I cerfify thol in Ihe performonce of 1he work for whkh this , permil is iaued,I sholl not employ ony penoa In ony monner SINN � O� CIN . � . . ��_ w as to become subjecl to the Workeri Compenxftion lows. . DISHWASHER � � ' � � -� " � oA �o�,no� ;se � � r,� ' opplicanl CLDTMES WASHER � - . NUTICE TO APPLICANT: If,-after makinp this Cerlificate of A�� �� � �� � Exemption, you �hould become su6ject fo the Workers' . SWiMMINGP00lRECEPTOR . ' -Compenso�ion pwvisions of the Labor Code,yoJ musl foHh• �qWN SPRiNKIERSYSTEM Clrv� � p ��`�'� 09�0 wi�h cwnply with such provisipns or Ihis permit aholl be STATE L deemed rero4eE. � � WATER HEAIER � ������� � CIASS C � IICENSED CONTRACTORS DECIARAiION a5ra�a rop. vxoCESSED Br I here6y effirm thot I cm litensed under provisfons bf Chopler 9 GAS SYSTEM � OUTlETS (jt'j (mmmenciag wi�h Seclion 7000�of Division 3 Of Ihe Businesf . WTLETSOVER . . . �a � rp and Professions Code,ond my license is in full force o�d effeU. � 5 oER 5�51FM FINAL VALIDATION 6 ticense Number 3 3 0 8 3 ?W - � DA� ��3_�� U 1 lic.C lau C'V a � � � � � p FINAI � O Controcfar � , Date L��aO'B7 . BY �, U ..❑ . . ' � LL.` . I om exempt under Sec y�� �B.BP.C.for this reawn � � ? Plan check fee :Q q�p� Date: MUMBING PERMIT ISSUING fEE f � - �slgncru,e �� FJ $(• • • • •rj - TOTAIFEE � . � •�� � a 5� �. . . . .. .. Plan check eppliconr � . . _ SINGLE FAMIIY • 1 1 8,5 0 c� � ' HOME OWNER-BUIIDER DECIARATION Nome � � � � - � -..�$2� �a 7 I hereby affirm that I am exemp�from tha Contractor's lfcense � Add.ess � � � � � � - � - � -- , Lcw for�the followirg raaaon(Seclion 7031.5,Buslnes�and � P�ofessions Code): City � Tal.Na. - � ❑ I,os owner of(he pwperty,.will do the work ond the � � . ; . . . . � ' atrocture is nor imended or oifered for sole(Section . . . . _. . . .. . . . . . �, -, .� , -� . . . 704d,8uainess ond Proiaxilons Code). � � . CONSTRUCTIONLENDINGAGENCY �- -- � -� �-� � ���- - ��� '� � � ��-� � I hereby affirm that rhero is a coastrutlion lending apency for �. I ' the performance of ihe work for which Ihis permi�is issued � � � - � � - � �- �� � - � - - �- - - •� �- � - (Sec.3097.Civ.C.). �, � . lender's Nome � � � Lender'a Addreu . ' � I certify fhot I havs rsad this applicativn and stale thal the . . . . . . . . ', ► . . . . . . ' . � _. o6o�e' ormarion Is cwract.�agras ro comply wi�h all Couny ' � . . , � ordi c s ond Stale laws regulatinq Plumbinq,and Meroby , , ,, _ . , � . _ . outh iz epreseMaiires f Ihis CouMy to enter upon the � � - � � abo - e e rl fo i�n ettion purpoaea. � „���p SEE REVERSE FOR EXPIANATORY tANGUAGE d ' ign of Pe�millee , Date . , . . . .... . � .. . .. . .. . . . . . .. , . . ., , . . , . ,. � ,: � , _. , . ., r. , -P.., r.... . �.r.. r,; ... � . �.. ; �.�, a. .., ! . :- . . . �� . �, , I .. , - . . . '_ : ._ :. ".. . i . .... � ' AFPPOVA .. ., '3ATE...�.'v PECJOt.'S$("�111URE I�l$P CTOf2S hOTE .. . . . �.. ' " �� lI1CF Ql,l �lt '"_1.��k 1 ��.1 � �� � - �r�.ff ) T— � - �UNDER5�A6V,:, \ ���f- .._.� � ... .-' . . . �. 1.. . \ . � . q,,, ,__...._.. .1.. 7r�rL 1 ��-�� t � p�T rn1L �[ n c � * �'rJ � I �, ROJGKGiUMnIN � � ,x�d D �7 .. ; .__._ . . .... .._.... .. ..._�,,..,_ l c .. l f tV�� fol��� � 7. p S cf 703t 5 . Gn5 PIP�,�JG �.� �!�� � ' t _ � • •. - . .. �2T' -. . 6usiness cnd Prolos:l .code� Any<irY or co,ni��.h,rh HO7Wl:7 � .: '. !` ✓ _�. .- � !_ ` ..__ r— ' � ���.,.� ` .. qc-Ys'cj'r f15c I I� p � nrri{,:h. ATF�NEATE� . ' -•`�`� �� -'- - ' ' ' "- �- . i hr` Y lJV �sf`u / ss c.ce 1 rc� _-"- "_ '�f . a_ � ..`�"-'_—�--_—_."�"�":;—...r-_-�- � r o- f q re� CoOp�<a lo f p Iff rr•o„o� d ic�e- Ftunta'�t�G vixrtJt,S`�- . .` �, T ,i ( � - eni nc��h �s 1 c�ns d F�.suc�r ro�h prov�sions o/nc� GaSTEST 2 -ql�, �.:___Tl ���:: � I .._^_____._._'_ ......__ . _._� ctm�ouo s[ic n c L�w�Choptc �9(c 'mc cing w�ih ..' _'_ . -.:.�... 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