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HomeMy WebLinkAbout1598A (9) � `� �� WORKERS'COMPENSATIONDECLARA710N APPLICATION FOR Pl.UMBINC� PEI�II�IT � ' I here6y affirm ihaf I hcive o certificate ot consent to self 76A667A � ,'„inwre,cs a cerfificate of Workers'Compensation Insuronce, CE 817(REV.10/81? . . - or o certi fie d mpy t hereo f�Se�.3 8 00,�a 6.C.1 COUNTY OF LOS ANGELES BUILDING ANP SAFETY P❑olicy N Co�mpany. . . . .. Certtfied Copy s hereby_fumi5hed. BUILDING '7 ` f�[/ �- � �� FpR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � J//��'I✓ � WL�(,`3 Ce t f ed copy i f led -Ih ihe couniy bu Id ng�insper ? tio depaetrt enf � NUMBFR FIXTURE OR ITEM @ FEE �OLALITY Dafe -� Appl�coni WATER CI.OSE� NEARES� -`CERTIFICATE OF E%EMPTIQN FRO(v1 WORKERS BATH TUB CROSS 57. . � � -� - - COMPENSATION�IN3URANCE. OWNER `� : ��_� � (?his secfion need nat be c3mpleted i!lhe�wark{nvolvad�y SHOWER _ - Ihe permiT ia for ane hundred doilars-(�IOb)oFfess.J �AVaTORv MA�� � A�ORF55,. r'?;J'p^+ I�certify that in the performance of ihe work foi which ihis a permif is issued,I Shdll no1 employ ony pe�son in any-manner SINK CITY TEL.NO.y���ji��^�� ��o - so as f�e�o me�ubject.to the Workers--Compensdtion lnws. DISHWASHER � - �y � CONTRACTOR �a G.y � rL{� DaT `r - pplicant "�`�'� CLOiHES WASHER ��«, + - �" - A�DRF.SS ,,,, -- a NO � E T APPLICANT:�If,-after making this C�rtificme of SW�MMiNGPootRECEPTOR �g � � � , Exemption, you shou�d�.6ecome��subject fo-�he- Workers' CITV .� �P-� TEL.NO���`"� Compensation provisions of�the.labor Cbde,-you mVs�forYh- LAWNSPRINKLERSYSTEM �p`-��'"yrI� . .with comply wifh s�dch..provisions-�or this�permit shall be � - - SCENSE NO. �J�°,f� .C ASS � deemad revoked. - -- WATER HEATER LIEENSED CONTRACTORS qECLARATION � DISTRICT NO. ROCESSED BY - I hereby aRirm that I om licensed undei.provisions of Chap�er 9 -� GAS SVSTEM OU7tE75 \� (rommencing with SectionJ000).of Division.3 of fhe Business OUTLEf50VER � � and Professions Code,6nd my license is in fu�l force and effed. 5 PER SYSTEM PINAL p �ATE V�nLIDA710N �; .� License Number � �`6 ��� Lic.Class���� � ��- � � � "�� p�y�p �' a� � �. . . � BY A� � '"�(s�✓yd s O7� � r Contracior � Date_ � I ❑ _. ,�.�... - .__. . . . � I pm exempt onder Sec. � _ _ � � 0.&P.C.for this reason ._. � � � 4-0 Plan check fee � . . . __Date: p�UMBING PERMIT ISSUING FEE$ �� y Signafure � _ � � TOTAL FEE. - Plan ch�eck applicant - SINGLE FAMILY � — -- HOME OWNER-BUILDER DECLA2AIION Name � I here6y affirm that I am exemp�from the Conirador's License Address � Law far the following reason(Section 703I.5, Bwiness ond _ _,,� �4 F�� Professions Code): City Tel.No. ❑ I,as owner of ihe proper�y,will do the work ond fhe {;��"' �' `� ''�� strudure is not intended or offered for sale (Section 7044,Business dnd Professions Code). �� ''�'�'i��,J� CONSTRUCTION LENDING AGENCV . � c "s: I hereby affirm ihot there is mnslruciion lending agency for ' ""�' ���°�'`?G� the performance of the work for which this permit is issued ����.��� . (Sec.3097,Civ.C.). � Lender's Name ' Lander's Address � � � - I certify thot I hove read this applica+ion and state that the � � above information is correct.I agree b comply with oll County � � ordinonces and State lows regulafing Plumbing,and hereby outhori>e representotives nf this Counfy to enter upon the � � above-menfioned properly for insFectior purpases. � � � ,� SEE REVERSE FOR EXPCANATORY IANGUAGE � . � '��-`=- ��. Signah�ef>PermiPtee Dnre �� � � � - '.� c� ��U LL � G 0.0 ,� � C ._Z7 '-O u �-C ` W 2' I � . . 9 �.M '` � � �� •�L� o a"O � O a' N C'�� y . ` . � 3 � „ r"o a a c c °- �' � . U�. � ' `�d Qa W 3 . � p' O N .°-a d„C . . . . . � � � Qi C� L �'�iJ '.'�- �{ 0�,:_ U Q O u�i j '� � . U 0 p� l�i p� 6 Ol 6'C O u. �'.- ':�� N t (Y:7 C_p�a. ' � . � � Q _� W t p b O D � w � o N � � a~. 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