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HomeMy WebLinkAbout1616A (9) WOR�ERs'�o,�P�Ns^T�oN o���ARAT�oN . APPLICATION FOR PLUMBING PERMfT � I here6y offirm dhat I hove�a cert�fimte of consent to self- 76A667A - , . Insure,or a certificafe of Workers'�ompensation Ir�surante, .-�'CE 817-fREV.10/91)� �-- - �- . - ' � � � or a cert fied copy thereof(Sec.3800,Lab:C 1 ' COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicy No ��47hF, Company"r_--AmPYlcd1°t .. . - .. . . .. . �. . ... .� .. - �� � �v�-����..•.. _ . . . � �. . Ceriif ed copy is hereby furr ished� . BUILDMG � FOR APPLICANTTO FILL IN(PRINT Ok TYPEI AD�RE55 - �Certified copy is#ilad with fhe couniy bu�ld�n�j inspeo- 20 Hd�1{W� Cl� CZ. tion department. . � NUMBER - - FIXTUREORITEM� ` @ . -FEE � LOCA4ITV , - Dale�'1-��$¢� APPlicant ��,e���}q'� �-� WATER ClOSET . . . -.. �. - '# NEAREST � . . � `- . CERTIFICATE OF EXEMPTION FROM�WORKERS'��- � -�BAiH TU9 r' CRO55 ST. ��.-. ,. .. . .. _ � .�� ._ _.__..� . � ... . :�COMPENSATaON INSURANCE -' . - - . �. - Ownle2 gonderosa HOIiIE'5-� �� (This sxilon nood no1 be complafad if the-work involved 6y - SHO'vvER . . _.. _ � MAiI .ihe permit�is For�one hundred dollars_�($106)or less.) � („ �LAVATORY - � � ' - •-" ADDRE55 �1 - �"' � '� Y'D- �I certify ihat in fhe perfbrmorice of the-work for w6ich this / � � -- - �- . SINK - CITY TEL.NO. ��permit is issued,6 shall no�employ any persnn in any manner l�i% ' _ . so as to bemme subject-to�ihe�Workers'�-Gompensallon Laws. DISHWASHER � � � � coNTaacroR Leavetton Bros., Inc. �,;- � � ��Da1e�� � Applicartt - . C�OTHES WASHEe _ �> �R� � _ ,� _ N^"CE TO APPLICANT lf. ai�er mak ng_fhis Certificpte oi - _ -��- -- -- _ -= �����-;����`. _- - _ - -- ! ption, ou�shvuld becon e sub ect�Ya the Workers` -:SWIMMING POOL RECfPYOR- `��� .�. y I � �CIT1' ' TEL NO. Cc,�npensatio�prpvjsions of the.Labor Code yo�m�5?forth- �AWNSVRII4KLERSVS7EM �ITV111 9��1�} 3-1]. �. ���, with comply wi16 such. provfs ons�ar:4his-parmit�shall be - �- � STATE -LIC _ �� deemed re�oked.� � . � WATERHFATER . . . . . _ /� �,.-� L!GENSE.NO.. . ' -`� '� CLASS � � LICENSED CONTRACiORS DECLARATION . - �� � � DISTRICI NO. PROCESSED BY " GASSvSTFM CIUTLETS ,+'` " -I here6y af(irm ihaf f am licensed ander provisions of Cl�npter 9 ..i . � - t✓� . .,r3 �� � r (commencing with Seciion 7000)of Drvision 3 oF the Business OUTLETSQVER - � - , .��R���. �?A � �"` nnd Professions Code;and m license is in fyll force and�effect -- -�S�vE,$'/STEM - � FINAL � v ���/d-,� VALIDATION 191969 / / w_ ,--- oa,Te � License Number_ Lic Closs C36 . � � - : . � . .- ..FiNAL . � Leaverton ' 2-13-84 ey ��L�C^��,��t� C8 l.� Conhactor -Date �- � � F' . . . . . .. . . � �❑ ,i am exempt under Sec� . .. . . ' .._ � - ..�. 0 aP.c.for rh�s�eason Plan check fee N � ;"P �1,bA . - Date: -p�UMBINGPERNIIT ISSUMG FEE$� �:(� � � Signarure — � rt� o � a a 5_ - . . � . _ . . . TOTAL FEE �t. �G�i . ,I A �E C E),�`(j ;- � � � � � -Rlan chcck-applimnt � � � � - � - ;� SWGLEfAMiLY � - � . _ ._. . �i_�1���CJ�.�i_ ^�� HOME�OWNER-BUILDERD�CLFtRATION ...,,, Name _._�_ „ -� - �-.. -. -<-z�. ,_:- -.' � -,— -- - ' �by affvm,that I am exenipt{rom the�Gortractor's-License .,.qddress ' - ' � � 7{ ��' J� � 4., . LL' L for-the-.following reason(Section-7031.5,-Bus+ness and�----- � � ,� - Professions Code):� �� � City " � � Tel.No. � - - . � � � ❑ I;as ownec of ihe.properry,-wiU do4he work and ihe' . � � � . � : � - � � t . slrudure is nor iniended or offered for sale(Section _ . ' . , . . .. . � �'' 7044,Busi�ess nnd Professions Code). �� - . . , � � . . � . � . � � � CONSTRUCTION LENDING AGENCY � . . � � � - � - � � . . I hereby affirm thdt fhere is a consiruction lendiny agency for . - � - � � � � _ �� _ - - � z: the per4ormanc2 of ihe work.-for which�ihis permit-Is issued- . � . �� . � � �� '"�� - (Sec:3097.Civ:�-C;). . . ... . .. - � . . �. .. _ _ . .. _. ._ _. ._... '_ . .. . ;d� � Lender's Name - -- . ' � . � . � . � . °�* Lender's Address ' � . - - I ceriify that I have read�his application and s�ate ihat�rhe �� � , .►� . . -- . . �- � nbove informafion�s corred.I agree�o comply with all Counly � - - - . ordi-nances and State laws regulnfing.Plumbing,ond hereby � - - - � � � . _ ._ - author e repre � tives ef ihis Couniy io enter upon rhe - � � - ; ubov entiorted perty for'nspe tiort,purposes. - � - . . f��� y��(���� SEE REVERSE FOR EXPLANATORY LANGUAGE }�.'� �eu:. a .��� .0 _ _ Signoture of.Pe mittee _ Da�e . . . . °'. _ I.'. 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