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HomeMy WebLinkAbout0920A � WORKERS'COMVENSATION DECLARATION � APPUCATION FOR PLUMBING PERMIT . /'� '. 1 hepby,oFfirm that 1 hove a cartificale of consent to self 78AB8�p . "�I insore,or a cerlificate o/Workeri Compensalion Inswonce. CE 817(REV.B/B9) . .. . . � . . � . . . .. . . . . . . u .. or n cenified copy�he�eof(5ec.3800,lab.C.) COUNTY OF L�S ANGELES OEPT. �F PUB�IC VIIOR � ��-8� Sfl��e. FOr� d �) / P❑olityNo. ompany - . . . - - � -'T' �'!�O �� - ., Cerlified copy in hereby Furniehed. � � � FOR APPLIC{�M TO HlL IN(PRINT OR TYPE) �����' . � , Ceriified copy is filad wilh fhe counly building in�pec- A�ORE55 �• � . � fion depo�finenl. . . NUMBER FIXTl1RE OR REM � ,FEE �����, _ , Dafeu...WLG?_[_-..AppliGonr�^I���C� � WATEBGLOSE� � . . ' � . . -. �� NEARE$i � . CERTIFICATE OF EXEMPTION FROM WORKERS� ' BATH 1UB - � �RO65 5T' �'Y�� . �. . COMPENSATION INSURANCE ��ER pWNER . : . � �Thb sMlon n��d aot b�compbf�d Il th�work inrolv�d by . . . . .. . . . ' �h.p�rme U for on•hvndnd dol�on(f10�or 4ss.) IAVATORY MAIL �c`� noo�ss 1 certify that in Iha performance of the work fa which this permil is iuued,1 shall not employ any person�n ony manner SINK C�Tv . ,.,96 � so os fo beWme subjeU b the Workers'Compensa�ion laws. ' DISHWASHER � � � � � _ , _ ' ^ ' ' GONTQ.4CTOR `�� j sPP�j�a�� - CLOTHESWASHER AOORE55 . � IVUTICE TO APPLICANT; I(, oher mokiog�this Carri{icaie of SWIMMING POOL RECEMOR � �� O � � ��� � �� �� - .� E.empfion, you shoutd become subjx� to �he Workers' CITY � . �Compenwrion provis�ons of Ihe lobor Code,you must forfh- �q�rypySpplNKlER5Y5TEM �U� with comply wi�h wch provisions or this permit shall be SiniE tK, ^ �� deemed re�oked. � � - � � WA7ER HEA7ER �����- � �Uu�—� �� LICENSED CONTRACTORS DKLARATION . , � D1STR�G1 nq. PRO[ESSED BY I hereby dffirm Ihot 1 om Ikensed under povisiom of Choprer 9 GAS SYSTEM OUTLErS � (commsncinq wi+h Set�ion 700D)oi Diviaion 3 of the Businees . . WTlF�50VER . . I D . �p� � � a . and Professions Cade,ard my license is in fuil face ond effecL 5 PER SVSiEM fINAL �j /'� �� � DATE `/��/'� VALIDATION O licenu Number "�� � lia Cloasy111Q_ U pp F INAL ,/ n ConiroctorF���Dme���'�� � . BY ��/�yt4� � f ❑ I om eKempt under Sec.�� � - � B.&P.C.for ihis reoson ► � � Plan check fee � o�<<: 5D � PLUM8ING PERMIT ISSUING FEE S :�B 2,O A - �Signalure _ . � � TOTAI FEE �' � n� •.• • • •5 ���. � SINGLE FAMItY . . plon check oPPflm�r ' . I •�� � a Jr O - � NOME OWNER•BUIIDER DECLARATION Nome � �� " - . � , e a � � �Jr�� I hereby offirm that 1 am e.empt fiom rhe Contrac�o✓s License q�ret� � ' � . low for.the followiny reason(Sec�ion 7031.5, Bwi�rou ond 0�2�`8 7 Profeuion►Code): � Ci�y _ Tel.No. �� - . . ❑ I,oa owner of 1he properfy,.will do ths work ond�M � � � �, slructure is not inlended or offe�ad for wle(Section � � � � - � � - �� - � - - - 7W4,Bu�inesa ond Aofesaions Code). . , , CONSTRUCTION LENDING AGENCV - - � � � - �- : � . �- � � � - I he�eby offirm Ihot IF�ere Is a conthut�ion lendinq oqancy for �� the psrformonce of ths work for whith this permit Is Iuued � � � � � � � - � ' �. " (Set.3097.Civ.C.). � � .. � lendei s Name � �. � Lendei�Addrau . � . . . . . . . . . . I cer�ify thot I hov�read rhis oppiico�ion and�ro�e�ha�the . . . . . . . ► . . . ... ... . . . obove formotion Is corract I aqree�o comply with a�l Coony � . . ordin n es ond Sta�e lowa pulaling Plumbinq,and heroby_ . . . . . . � . . . ... ._ .. ou�h riz rop eentative� this C My�o enbr upon fhs � ' obo s• �P�opa or i s �ion urppyes. � . - . . .. ��,,� SEE REVERSE FOR EXPLANATORY LANGUAGE ..11 .. . . � _ . SiqnaWro of Cermi�e � Dote - � i .re ^ f { - � R• � �i: . , �: �� ,. . ,_ , .. r- „- . , , .. ,.. : t., . ,_. .: . :. ... : •. t, i s, .r '... k . � ,��.,:. ;,., ,,_, . . ., � ; . � I�SFEC OF S hOTE :'... ' '. ..� �:. '�' J 1i �Fi� ��k Ct�L!k 1.� . � . A F.�Vf LS _ I11 �,J<FEC�SICN_ 1TURE ' f �.. .. . . . ' UPJDER SIAB WOFK. .. :-• E�� � . �-� �j . � . . S . � ,- . .5 jT-' ! c cny� f� � i I a � N � r .Co� c � ROUGHfLUYt.:.G '...� _ ' /a�.�r "'_ _--___ �.__......_. .__ ._ �_ _..._�.._. -��� L c �sr la f� d f�I � � �.r ��,Secf l031 5. GAS Glo�,ti�, � _/ �, - � � , ��'I� 6usinesz c f Fro�c�ssions Cod�� Any cify o�roun��wh�cn Gn5 VEIiT .-._ . . . . ... _ -. - - ._ .._- . �� � f l��.'- . - - .� � �eqvir•s c prr i�t fo c7nstruci.�alto; mp.o�ic�,�demol�sh, - `" : . i .. r . ,. � , . �, i �_.._. � ' i cl t i , . . � --- �-.- - - ----- '---- � - ---- re oir s r ure r or o s�ar,c c so re� r p ny N p i HpTVJA7ERHEATEB.-_.__ � �' �" �1 .i�� � � '.�. " i :� .•,''. qorosfbo��pLmrl�forsuchpermllt blc.oaigneds�air � `• -. ._ _ ._ ,... _ ..._ ,`., <i r -j , �._:_. �.--.-'i___ *___._._ '_ ' '___ ..__ + ' "'_. .•.� meni�iho�6 f��c s d p r enr� h-provisions o/ihc FlUMZ1�GFIkTLIRS�.....,`.�� '..���,- � . -: , -`- .. � � r_' _ � GASTE51 ..... . � . . . —T . .. `T , . . �. ._- ._.__ ._ C ntracfors Cic -e�La ..,fCh�pl 9(cemmc c g rth � �� � ;� � S ctlon 700/ol O vi on�'o�fh� Bus ness o d P oJes� UiILI7YCC..I�I'J:�FIED___.___"'___'_. -'''-- ' --- �-- . . ;_.._ .I� _- -.---'.- �J:.:� .... ";- . .. � (�rd"C,iCrrf Ilonmf.rnfi vea7olrnondfhe'bOsis - i 12 CO?C)(` II['t I ,, � � � � fo fnc o I p y ol•Scrfon '—--_�. r � FINn1 � . .•. . 'l ' �rnrtl � i � , . . . �. , � �7p3I.5'by an�tiF.plicant(o `o��c �1 s bjcds tFe-appli� , .: � .,.nl� .a�� , ., � . . :- �I ' _.__..__ _�_.____ �.�." tanf�to'o�trvJ PdAdlt� ('nor n��re fhan�five hun3red �� --, . __ -- -1- - - - - . .. _ --- . � ,. , �doiia��rssoo�; !NDUSTC.4L'— '._.._.-,_. .Tt.- t '-' . .___ -.�= . _ . .---- ---- -.- .-- ❑I,as o.vnar cf Ihe p�opert�.v II co�he wor"`nd � 1 � i S^JAS7EnFPNOVAL �" ', � - ' - .�.,,'__'� ___ ._ ..._... `__—"'_ � - -.--- sLoclu��nrci�mtendedorbfiered�fcrn�lr.-�` . r , t ..__- __ _-._ -�he I --- - ��- - -� - �--- - - � ' - -�, (Sec-704d 6 lnciso ;1Frofess�onsC d �7h Conliao ! _ . , � .1 . I ,.'- ;.'____. .; _ ,____ '...."-` _" _ ' ,_......._ ,�' iors Cicense Ca v dcis no�apply�lo 0 0 � er f p eper! i-.- -. '. � . . . l } . __-'� �, � � �. . . .v.bo 6uilci or�nnproves inaioo nJ wfio doei'such ( � � �� � -�• � r I -�^�T-� � worF hIm I! rovided ihai such Improver�c �s arc�no� l._....-.. .:_.. -_'."._ ✓.. .�.- -„- .f.:, 7 _._ .., ; ' ' � ...___'__._. .___� .. -_ ` I�fenJrdoroleredlorsolr..il,-howrver.�fhe6ulldingor � �'. �:�, ' , '. � �� , .....-f— i-,, - _ - . ,. improvemrnl is,sold w'thin one y .. al cpmple!ion.1he •'� � � i. .� ' i � �--.� •; --�.- .. . ..--'-'-�--. ... ..--- �--' ' ... owntr-6oi�dcri�-Illhcvelhe6urdcr.o(provinc�thclh�did � ..___.__� _-i . __.___ __._______.__. •. . . . . �.� y r�.: . ' i .. �. -. ..__�—�._._..�r---_,_. _-_____ � �-`.. __'__.__'! ....not build cr.lm�.rov�(nr ine piirpose of snle l „ .... � . �___..�_ . .�._. : .� , i �' f . . . . , . � r �. � , i . � ,. _ _ ':-__.__._.._'_____'_'___. . . .-_.__� .___ . • . . ...:.._._.__-.__- _ ' .i . .� .i' _ . � � . �t am exempt�uiidar S ,. . , .. � . 1-..i�� I . . I . �. �� � . ... . ,. . j � �. . � _ �-cT . - - �� ,�,. .,, .,:- _ � .. . ' .-._'..____-__ ._:. ' ' , ' .`__ ' � . ^ i: �: . �..:._ `.... . ...�.�;�_: , E3 E P.C. for tnis re�so���- -- --- �---�-_--.^ '_-. _. ..__. ...--- _� --- .__.._ ._.__._.. . .. - -- --� -T—_ . , ,. . . .. � � , � . . . _ ,.,,. .,.....,.. ; . ! .__.__ ._.___. __._�. __._ . � , -� , -- .. . �-- -r -- -� ,,' � .. . ,�.,.� � , , .___� . .. ._ _._ ._... _.. - --.._._. ; .. .,. . � . .,. .. - -_.. _ ._. .. ..._.__ _...------'-.. ...--- �, , , n,«�-- . ____._._� , ,_ �,... . . _-_. _f._ ' _`_.__..-_'�- _�_—__ �_ . . .-_ � _'_''_ __ '.. _._ . .__..._ __'-_"_'�' '__'___._'..._..__..._._ "_____ ._. ... , . � -• , � _ ,^, �i 4 =' y .. , . . , .. . ._. : . . -...-- . . .T owner r.., . . . � . : � . �, .� . i . , . .. ,-. . . ., . . � . ..�.�.. . . , .. � r - , - �� �� >__..�--'�-.-._--`-.'_� ....---- -.__�._._�..-'-' _--_' ................' T_ _._`__. . .. ''' I�dSPECTOR'S NOTES s c--. r ,•.,.. --..:. i_c�:� _ � �:- � ` ,_, : _ i--------�— � . ,, �, . _ , _ � ., --- _ _._.__._,___� _--- i ...,: , ,. � _.._----_- �---__ ____ . __..__...__._.. _ ._--.. . -�--- __ __ I, � _: . . �,.., ,"� � . -_..___..._._.._..__.__�__.._____...__... .: ':' .�. ,i _ - --- - ---- _. � ,- ,.,_ �. . ;...; , , . . . ., . . _�� � . i