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HomeMy WebLinkAbout0925A � WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT � - /� � I herwby,affirm liwi I hovs a certificofa of conaen�to aeif �OA667A , . . _ __ � -v�� insure,or a certifimb of Workeri Compensafion Insorance, - -CE 8ri(REV.B/88) � ' . . . . , I 1 � . .., or a ceriiiied copy�heraof(Set.3800,Lab.C.) . . . . � � � . - � IJ Q�_(�'� �,tA-�G �vnd COUNTY OF LOS ANQELES DE , . OF�UBLIC WO , '.. Dcy No. ompony . .-. _ � .. . . . : '1�_ . Cerrified copy Is hereby f�rnishad. a� . �.� � � � FOR A7GLICANT TO Fitl IN(PRWT OR TYPE) Btl��qNG . Certified copy is filed with ihe counly buildinq Inapec- +��� • �O ti n dapanment � NUMBER FI%TURE OR ITEM Q FEE , ` IOGIIiY . . .. .. ..Da�e -�� � AppliSaM �„� � ' WATERCLOSET . . . r O� ��� . . � �.CERTIFICAlE OF EXEMFTION FROM WORKERS' o� � OwTM T�B . . a C��. '. �� � COMPENSATION INSURANCE p�yNER . � �� � (TA4 wdlon eNd not b�tOmpl�l�d iF M�work inrolwd by ���p 00 � � - � - . � th�p�.mN Is fer on�Avndnd dollon(f100)er Ins.), . . uv�ioRv - �'�� � - � � � .. .ADDRESS � I certify�Frof in the performance of the work for which this . � �, permif ie iuued,I sholl not employ ony person in�pny mpn�er S�NK ❑TY C . . , � _ s � . so os io become subiect�o tha Worke.s'COmpensoli0�LawS. � DISNWASHFR � ' � � p coNrnncToc j�C p �. � � 3 ' Applicant � /� � CIOTHES WASHER . � � JTICE TO AFPLICANT: If, ofter moking this Certificale of SWIMMiNGPOOLRKE7TOR ' ADDRE55 S .._ �Eaemp�ion, yo� should become tubjact lo the.Workers' � U7Y/n i� , Compemalio�provis�om of the Lobor Code,you must fath- �pyyN 5%tINKIER SVSTEM � " � �� e � _ � with tomply with such provisions or thia permil shall be $Tq7E �Q CUSS C�� I -deemed revOked. �� � �. � � WATER NEATFR ������� � UCENSEO CONTRAC70R5 DECIARATION a DISTRICT NO. PROCESSED BV GASSVSTEM OUTLETS � 'D �Q I OT` �' �I hereby offirm that I om licen�ed order proviaioos of Chapier 9 � Da .�commendng wi�h Sad�on 7000)of Divtsion 3 of the Busineas .. OuttEi50vea a -ond Professiom Code,and my lice�ne ia in foll force ond effect 5 PEN SvSiEM FINA1 �/��,/�_.f VALIDATION V Licenze Number- �����7 lic.Class� DA� 7'� R Fi�� � � �0925A o n p �� Controc�or �` �P � -Dale.C1 aU�CJ� BY � a �!• • • • e�j V i ❑ . W I am eaampt under Sea . � • � Q(j,5 p y je.aP.C.to�ih�:reaso� plon check fee � • ^ 1 0 L�5 0� Z ' � Data: p�UM81NG PERMIT ISSU�NG FEE 3 � �- O H.2� �S 7 Si9noWre �. � TOTAIFEE � SD . � �� SINGLE FAMILY Plon check applicant - � � - HOME OWNER-BUILDER DECLARATION Nnme � � - . . . . . . . . . �- I hereby affirm tha�I am ex�mp�from tha CoMrocror's Ucense . Addreea � � � - � - � � � - � � - � - � law for�the followi�g reoson($ectton 70�1.5,Bu�inesi and � _ Professiona CodeJ: Ciry Tsl.No.' � � � ❑ �,oa owaer of the property,will do the work ond the -. � - ', � s�rocru.e�s nor Intended w offered for wle (Section . _ . . . . . . . _ . _ . . . . . . . 70t4,Bu�ineas and Crofeuiona Code�. � `. - �. CONSTRUCTION LENDING AGENCY � � � � �� � � - -� �� � � -� ' - � � � - I hereby offirm tho�the�e is o construttion lendiny ogency for ; � Ihe perfwmonce of�he work for which ihia pe�mit ia iu�ed � - � - � �.. � �� - �� � � . �- - � � �� I, ISea 3097,Civ.C.). - . . ' Lender's Name . .. . � . � . . � lender's Addreu � . . � . � . . . . .. . . I certify�hat I bave reod this applicofion and s�o�e tha�ihe . . � . . � . . . � . ... . . .. . . . , obove info�mo�ion is wrrxl.I og�se b comp�y wirh oll Cwnry � � �� wd�n ss an Sro�s lows equlat{ng Plumbinq,nnd hereby . _ , _ . . _ , . _ : . . , , outh riz r�p entotivas f thi unly fo enler upon Ihe � � ab �i d p or i c�ion pwpoua. SEE REVERSE FOR EXPLANATORY LANGUAGE � � � i Sipnature of Permittee � Dola � �� � .E: .�. � . . . . . ., � , .s'. � .. �r.. .. .. ,. �t'. t.�,�.:� �' . � , � i . l L� r ._,, nPGRovhi . cnT 1NS'SC70R's�!G�;ATURE � INSPECTOR'SNOiES t'- .•..� �.�_. ,. .� IV�ltF'r1IL�ER�Dt [ RA�I'�l � . � �LJNCCR$LA9 NJOFR. `� ���f7 ' .. - �.: . a � �:.1 Y :�.. .. � . - . �. � .`S'_�j �:�i... __ �.—.�_ r ..' ,:.: , � Busin ssa`dP o/os o sC de'uAn ct '„ c �r'• ROUGV{GLUM�hG -�= �J -._._.... �.... �.... ,._..,,,._�,,,..�.,_.,,., i � e � i �tic rn�o n;i i o �.(ser�0 103 i s. ; GA57Ii.NG , �.:,. � , . . rP . 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P . �( �J U'iIITY�C0.��k,iIF:EO -''----- ' �-.~". •..— _=--=.—:-_.- ' '. .-".'. � . 5 cfion 70J0)of Div s�on 7 of�fr c��usiness ond P�oles� ,,,. _...__ . ___. ____._____ __ _.._ .�____._ ,— ;". .s7on�sCod)er�fti-f�fc se Cm;Yfh relmmp�dthe�6azrs c-7 , j .: � .. � i 1or')ne o!lcg�d c •mprron Fny b�olnbo c/Sccf'!on FMAI . ..�. �� .rn� ti�e_iro�tl .__,'�� �.�'� � _�_:m ��—__�.__ ...� ....J— . _- � �� c.. 90J1.5'L ao a �X ont(or a� if '!,(c r �rho oppG� ; �' �- % v I � � . ' . . .„ / Y r'P�� .P ._._ . . . . � . .. � ..__ � � -- ' . .�. i '.� .. -�- - � '�dollors�(5500/.I rc��lY . o�r; . rhar i vc hu ed _j --'T �. . . . � � � I o ' �� !NDUSTf�tl-- — . _ ._. . _.. . ..._ '.�. _._._ _. -___ - .. ❑I os o �nm c�rh �rcpa y �11 dc d v � -,d. �r:e.STE.�F'�O�n. ___.._. .....,_ . .. � .�1__ '.` .._�___ .__t_._ . __- _ .;_ _.. __ �h �strocru �nprt d .i'er'ocedf..-sl .', 5� �— - -- � � (Sec.7DQJ E s7n�s's andFro�ess ons Cod�•. �7he tonlrec- �� .. - . .- .. -`-..�.-. -� .— .. .. ...—_ .. for's��Ucens Lori.�foes�olo�plyfo n-o,�nef rProperfy "- � — -' - - - � I '��� ' �'�' ��. � who �u Id . r im rove lhere e-J wha dees iuch ) �� � _ .." �;�. i . �� i I �. . ,� work h�m�elf provlded Ihet such Imp ove.meo/s orc�no� .,..... , �.. c."'� . .:_ . ._ .. _.� . " � i �.�.. ,: � �-. . , ��=�.� ' -''---- _.--t----__.-...__ ..._._._`_-.__ ..._.� inlmdcd.o•of,lerp:i(ar scl��1�,he�vcvcr;ihc building or . -- t �i ' � ! r . 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'_ ________ ._..___ _ . ._. ,.. ... ..., . � � ._ . 4-. . .___.._. ._ __.___ __._._ —.___.. . ._.____. �__, ,_. - . . ., i .____ � _, —_' ___ __ ._.. .. ...'.. '... : ._ . . . . , ..„ _.._ ._. .. .. .�. ,,..._ ________—.'___._. _ . .. : _ � . � - . '. i . ':" �': ; '_._' _'_-..—. _ _:.. .__._ ___._ . �—__— Uutr __�_--- ' ;__ . _." '. ____ �. ..._-__.__.._—_. .____'___- _._. ._ __ __... . � , ' '___.'_'...__ __ . ... ......... , � . , . Owner - . . . . .. i . . . � . . . '.i,.:... _ , .. ' . .._ �._..,____. . .___._ _ .__._ _ __..__. . :, . . . ... INSPECTOR'S NOTES ���- '�: t.. :..� :�' .. �.� , F�-- ---- -- ---- ---- - -'-� .i: . .. . . � .i . . ., , � . , .., ...,-, ,� ., � . . i �. . . �— �,.-. ,. .; .. ; . ._... ,��.: . i-...--.".--- ----'- "-- '---........ � . . . . . ... : , __�..---_ ' - . , . .. ... ..�, �-' �..-., ....- - ..., _ ,. . ;., - -. _ � ------- - __.__..._--._ . _.___ . . . . �i . � .. . . . � .. �.. 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