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HomeMy WebLinkAbout1612A .. : �- . , , � WORKERS COMPENSATION DECLARATION � � � AppLICATION FOR PLUMBING�PERMIT � - �I he�eby ffi tha� I have a certificate of�mnseM to self �yqb��q � . .. . . � insure,.or.acerii£icats.ofWorkers-Compensafionlnsurance, C.E817(REV.10�81) ' . � � � �-- �����' or u cerflfied copy rhereof�Sac.3800 Lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY .Pol cy No.�.g.$1��ycompanv 4'i� d1lRe�ls'lll . . . � � _ `�d�. J�L.�� . . � Certified copy is:hereby furnlsh d BUILDING�. � �-�- " - � - FOR APPUCANT TO FILL IN(PRINi OR TYPE� ADDRESS . - Cerlified mpy s�filed with the county building inspec- , �ion deparfinent: NUMBER � FIXTURE OR ITEM (a� � FEE LOCA,LITY . DTdIRORG��-B1.0 .Z-],$-$� ' L2dV2L't.011 ,� � WATER.CLOSET - � '~ NEAREST � Dafe Applicanz . - -. . � . .. � 9���. BATH TUB CROSS ST. � Y; CERTIFICATE OF EXEMPTION�FROM WORKfRS' �� - � I '"' � - � ' � .�-- � - -- CDMPENSa.TION IN5URANCE- � f sHowee � � - owrveR ponderoa --Homes ;; (Thia sedion need�not be comp{eted if The�work involved by . . �� �� MAIt -���� �- �� the peemit is�for one hundred doilars(5�00)ar less.) �LI�qvniORY - � ADDRe55 6ce��tify thpt In the�performance.oflhe work for which this � � SINK - � �� CITY - - TEL.NO83j-2].$0 � permit isisFUEd,6shall not employ�uny persan in any manner � a r" - "•� , . so as fo become Su6jeci to fhe�Warker5 Compensafion Lqws. � / DISHWASHER . ._. .. . � � � �- - � � � . � ����> ��COMRACTOR LeaveXton�Btos, - � Dale ..� .. �+pPlicanl � � - CLOTHES WASHER ADDRESS � � �. . . . . N"'CE 'f0 APPl16ANk I#,�aNer mpking iNisCertifimfe of SWIMMINGPOOLHECEPTOR _ 1 21 � .E ptfon,�you.should become su6�ed fo the�Workers' . Ci7Y TEI.NO. . C����pensation provi5ions o411ie Labor Code,�you musf forYh- . �qvyNSPRINKLER5�5TEM � . with mmply wi�h such provisions or ihis permit�sholl 6e STATE �IC � dee.��ed revoked. wn1ER HEnr�R iiceNse No 191.969 ctnss C36 � .-LICENSED CONTRACTOR$DECLARATION � � � - �DISTRIGT NO._. PROCESSED BY� �� � GASSYSTEM t QUTlEfS yp � � I hereby 6ffirm thol I am licensed under provisians of Chapter 9 �J � . Gv� „t - , �, '� (mmmencing with Secfion 700Q)_pf.Divisioo 3.of ihe Business . OUT�ETSOVER .�, � � `� ` 5 PER SVSTFM �^ ��' ond Professions Coc1e,and my Iicense is in full torce and effecJ. � � � � FINAL {y 'J VALIDATION . ,. ,(,.��- .,��,_.,sJ,� - ,a,._. DATE �•J'�'Y'�8� . . � �, License Num6er -197_969 ���,Class C36 . � - � . . - . � � BY AL � '.�. _ . � ��. cono-a��o� Leaverton oare 2-13-84 � ..' ❑ I.am.exempt under.5ec- - - .... .. . . . . . . . . . . �A ` . . . . _ — . a�nD i; .. B.BP.C.for ihis�reason� . � � �. � � � � . . `�' @�- Plan check fee . . �1e� PLUMBING PERMIT ISSUING FEE$ �(,�- (� � � i* .- __5ignature _._. _. � .. . . - . . . . �. . . �TOTAL FEE �C�..�i - � r}-G�,��A . `, � . . . .. . . ... .�-.� . . Plantheck applicant � . � . . . . . � . � SINGLE FAMILY . � � � � . - . �� �;�� °'" � �'�� . - `NO(JiE-OWNER-BUILDER DECLARATION Name --� � --� -� -� -- � � � . . . ' . ,' -by affirm ihat I am exampt from ihe Confractor's License Addiess � . � � -, � - � -�E " �d G�'J l) "� .L. rorths following reason(Sectlbn 7031:5, Business and - ,. . .. . . . - . � - } .- ProfesslonsCode�: . . . . . .Ci�y . . .. . _. . .Tel.No. - - . -. . .Gje � (;�,J Q u . ❑ 1,as owner of�ihe property,wil�do the work and fhe � � - � - � -- � � -�� ��� - � . . � �,i �+-��� � structure is not in�ended or offered for sdle (Sedion � - . � _ � - - � � � -�- 7044;�-Business and Professions Code). � � � . � - " � � � CONSTRUCTION LENDING AGENCY � . - .. - � . � �� . - _ I hereby.qffirrn that.ihere�is a cpnsicuction lending agency for -. -- � � � -� - � - � � � � � �- � � . � . � `� the performpnee of ihe work�for which-Ihis permit is issued . � � - � , - - � � - '�� (Sec.3097,Civ.C.). . . . � � � - � . . . � Lender's Name . � . . . . . .. . . - � . - . Lender's Address �� � � ' - - � -� � � I e tity thal I have read this applimtion and state ihat�fhe � � _ ._ . . .. .. . -► - � above information is correct.I ogree to mmply with.all County � � - _ . ordinan2es ond Stafe Iows reguloting Plumbing,�and 6ereby - . � � - - . . - aufh rize repr�e talives f this County fo enter upon the � � . . . , � - bp -menli�tlne � r�riy or inspettion purposes. , � . � � . . .. � �c � ^ Y �SEE REVERSE FOR EXRLANATORY LANGUAGE Signature�of Permittee Dote . . � . � . - � � �:o a� -�°x �i➢ c .� � � � � �, � . � �' ��_• �y�� �� �z F� � N ��� �"��� � � o ,� � c� ' - iN�� �� �� �1. � j :�i !� Q 9 m=' � � � i � C3 �4 � �,r, �q 2 x' ua� .. - -. � ���q� � p .G �'t�. � 4� � � g , + ; � A i � � �� � � � ��° � � � v ,'} - � � � � ,�.. ,�?� � � , s� ,�� � � �.,, �. �_ ., � � . 1 � �' � - �` � � � � °� `� ! � - � � �° ;,� ; � � 1 � ` ;z � � � 1 � , ;� � � �, � � ,� , � � , � � t, � ' � j ` �,. a ; ��� t � � a t, , � � } � � � 1; � � , � � l � � � � � � � � �� � '`; � �� � � � ` �� � �� ' � ��� � << �� � � � � � ��, F �J �! �, � � � �� `, .� � . �l F:E�t . � . . � � �� . 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