Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1612A (9)
WORKERS COMPENSATION DECLARATION � ��� �� AppLICATION FOR PLUMBING PERMIT � - `��'�I he�eby ffi thn� I have a certificate of.mnsent to self 76A667A - -� . - � � � insure,.or.a cerii£icats.of Workers-Compensafion Insurance, C.E 817(REV.10!81) ' . - � ����' or a ce�flfied copy+hereof�Sac 3800 Lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY .Pol cy No. � tin�.�won 9FGCompanY Ca� 11lRB��6'ti�l ' . . � � `�A�: s�Co\ - . � Certified copy is:hereby fumished BUILDING . � .-�- '.. . . .-. . . . FOR APPUCANT TO FILL IN(PRINi OR TYVE� ADDRe55 r�� ....rL...,.+.�+.�1 �Rr� .. r Cerliiied mpy is�filed wlth the county building inspec- i�' , �iondeparfinent: NUMBER � FIXTUREORITEM (a� � FEE LOCALITY _ DTdIRORC�-133C .Z-]„j-$Q � L2dV2Y"t.011 ,� � WATERCLOSET - � '~ NEAREST � Dafe Applicanz - - -; � . - � . 9�� BA2H TUB CROSS ST. CERT�FICATE OF EXEMPTION�FROM WORKERS' �.«� � � I " � - ' � .�-- � - -- CDMPENSa.TI�N IN5URANCE- � f sHowee � - owrveR porzelexoa -Homes ;; {Thia secfioe need�not be comp{eted if The�work involved by ---- . . - �� � �� MAIt -��- �- the peemit is�for one hundred doilars(5100)or less.) ���qvnTORY � ADDRe55 .�$9.R��� -'n�e ('^nt^r 7]' �� �, I�certi{y thqt:n.ihe�performance oflhe w�rk for which this � � SINK - � � � a� ,�, CITY - . .,.,. - TEL.NO83j-2].$0 � permit isisFued,6shall nut employ�any persan in any manner � � , . so as to become su6ied to the�Warkers'Compensation Laws. � / DISHWA�HER .-� �- - � � ;��r��_ �- � � � � �. ����> ��COMRACTOR Leave�ton�Btos. - � Date �� �+pPlicant � - CLOTHES WASHER ADDRE55 � � �. . . . . N"'CE TO APPl16ANk I#,�aNer mpking iNis Certifimfe of SWIMMINGPOOLRECEPTOR _ 1 21 � .E ption,�you�.should become su6�ecb fo the�Workers' Ci7Y TEL NO. C����pensation provi5ions o411ie Labor Code,�you must forlh- lqVyNSPRINKLER5V5TEM � . wifh mmply wi�h such provisions or ihis permit�sholl 6e STATE �IC � dee.��ed revoked. wa1�R HEnr�R i!ceNse No. 191.969 aAss C36 � .-LICENSED CONTRACTOR$DECLARATION � � � � - �UISTRIGT NO_. . PROCESSED BY� ' � GAS S�STEM t QUTlEfS �yr � � - � �� I h eby affirm thot I am�I censed under provisians of Chapter 9 . �J , � . r�� „t� ,� , � (m meqcing with Secfion 700Q)_pf.Divisio�3.of ihe Business . OUT�E�SOVER � .�. � � `� ` 5 PER SVSTEM � � 1 �- {�' and Professions Code,and my Iicense is in full torce and effecJ. - � FINAL �ry 'J r� VALIDATION . ,. ,��- .,��._.,sJ,� - ,a,._. DATE �•J'�'Y'�81 . . � " L cense Num6er .-197_969 ���.Glass C36 . � - � . - � - FINAL � � � . � � �� cono-a�+o� Leaverton oore 2-13-84 eY ''•�^� � ;' e� ❑ I.am.exempt under.5ec- - - .... .. . . . . . . � � �A � �8, — �,a s.BP.c.for�h�s�eason Plan check fee � � . . �1e� PLUMBING PERMIT ISSUING FEE$ ,(,�-�(� � � �s ._ __5ignature __.. _. . .. . . - . . . ` . . _ � �TOTAL FEE �C� � I='4-C��,t�A � � . . . .. . . ... .�-.� . . Plantheck appliwnt � - � - - � � �. . SINGLE FAMILY . � � � � � - . � �� �'�� °'V � �'� � - --NONiE-OWNER-6UIL.DER UECLARATION Name --� � --��- -� -� -- - � � . - . ' . ,' -by affirm ihat I am exampt from ihe Confractor's License qddiess � � � � -, � - -� -�E °� � G�':�l� ��� .L. rorths fallowing reason(Sectlbn 7031:5, Business and - .. . . _ . - . - } ' Professlons Code): . . . . .Ci�y . . .- . .. . .Tel.No. - - � -. . .�'e � �%�•�C u . ❑ 1,as owner of�ihe property,wil�do the work and the � - � - � -- � � -�� ��� - � . . � '��,i �"-��� 1�� structure is not in�ended or offered tor sdle (Sedion � - - _ ' � - � � � -�. 70d4;�-Business and Professions Code). � � . � - " � � � CONSTRUCTION LENDING AGENCY � . � .. - � . � �� . - _ I hereby affirrn that.ihere�is a cansicuction lending agency for -. -- � � � - - -- - � � � � �- � � _ � � . � "� fhe performpnce of ihe work�for which-Ihis permit is issued . � � - � , - - � � - (Sec.3097,Civ.C.). . . . � � � - � - . . � Lender's Name . � . _ . . _ _ . - � . - . Lender's Address �� � � ' - - � -� ' � I � tity thal I hnve read this applimtion and state ihat�fhe � - _ ._ . . .. . �► - � abo e informahon is cor ect.I ogree to mmply with.all County � � � _ . ordinan2es ond Stafe Iows reguloting Plumbing,�and 6ereby - . � � - - . . - au4h rize repr�e taiiv f this County fo enter upon the � � . . . , � - bp -menli�tlne � r�riy or inspection purposes. � . � � _ . . _. � �c � Y �SEE REVERSE FOR EXRLANATORY LANGUAGE Signature�of Perminee Date . . � � . � . - � . . �'�x q����tO���� G `1 rq' C3, Us �G5 'Jq , K � � w � � � � � � L. f � � � ro � � . . �Z �G� � � �, �y .� ��G\s� � . . , . .NG .�ty t--t' .fat� .'�0a's, , � i w1�z G ,a� p � �-n y 1� "�G"i �'�. �R` �+, 2 '° u+*� _ _. �y�� � y � .�, ��s�� � ._ " . - ��� � Oi �R� A- �` �. 0 a � � � �� � � � �9 ' . ._ ,. ' . �� � 1 .' . . .._ " . ' . . . ' . 11 ... . � ' ' . � . . � � . lA.�1����� � � . . . � P4� p�� S 1'..`w.,�,�. . . . . . � � .W� � �.- �� � ' . . . ^ � �':. � � 1 r ' " � , ' ,,. '1 � � !P.� , \}� S. T� Q � � � � � � � 1 = �' � � i� � \\: � � ' 1� � � ` � " � ..., �, ,� . � j � � � ` . ' . . " . - � t � ��, ,j . . . � . . - . .-�`- ., -� �`�\. �. ' - ' , '. . . � . . �` �. ' �. - � ., .' ��. . -. ... . '� . . . ' . � , � \ , � ,, � } t ` �, ` � . r��, �'� �� i ' � � � �;� �, � � �_ � � �` �� � � � ��; � �� �. � � �. ��, t� i '+ �;, @ � � l � :� `p` l tj b p \ . �. y � �; .i. � `. . 1tk � . . .� �; �4 � � � . , 1 '. - . , . - \ , t . ` �„ 1 � �� - � _ �, � . . .� - ��- . . � , ` . r . . . - . . � � . t �� � ; , ``;,f ,` 1 '`�t `� � � ,� ... � � � � ¢� �� ro N-�4 Cs.AD��=i C 3 N �tS �� � . ���tl�.g n �.�,�,,�'�b � w f�G . .. - •h3- C�,�e�.+ .�* O C2 Q � p g ..� ` '� '&�� qq� 4 ta S�� r° R.�n 73.� �'t. .-K^.�,,., L� _ . .. , � ., . �.t����"' �qg n» n "��' Q.d C ¢oD K��K� � C � � . � . - � . . . . � � 9 � 6""�0 <!�' . a^ � 3.0-., `3.' ,� ��t� 9 � Lg-W � �:.S"��@ ,�G t.2 ��° � yWg� n � n� -N ��+'� '6'3 . �a � � �' a�o �.� �.� ia'n �<,.e @ so.��, �,� � �� � G (� n -�z �a n'.�,� �,� � �� ,� �:. „G.�.�s'"Q�� � �o � G.° �*�' ` � � m t"� w� a w.�+ � �� �+ Wo�, ���� "ma<'-w `-° �. ct5w � ' � o ^� � �s w�3-�9`" ?. l,. ,.�?� � � �.'°c 3'� n° " O a.� �a , . _ , . . . � . � 6 0�� a.:�,o''Dw .nj � 5 0 - K.`o C8-in -x3.� ' �•`O � � . . . . - . - . _ . .. � � � � o � � � g � � � � � - � W ` �° a"v; o,°� m .o .� ta 3 Q� � 3 ° �s� o ''" � `" {p . o;� � ;s_ .... �..��o °�m �� 3�� � �1 n ° ° � j Cta-- ' . �. ,���.�,.� O � � � . ci1 O .it� a �i , .-1 � � � �;� � � r�� � :� 3 -� � �.r, m, � 3 .e C? . . . � � . - �i 6� -.C'. -. �'cj �.� .u:R.�"'G 47.�"G ��< C`w n�. q��C'�.�3 a�. . L- . . . . . . ; . . , � � �,�:� t�5.� � 3 a� n c'"% . n c�� N�°n•� � c � ° . . � � � R`�in� : a_o�''' ���° rz c en � ' d� Q `�'° �' °.� °<""z. �o' ,�� t a�u'��y,� �'�-° 3 g .c,�' �, -� v � � � � g -' �,9 c� m y. ; -ca�c o � c o _- � - -'^Y � � ��, 3:� `c a� u+;o n c, �.�v� �' , _- � . . � .. � ". �° (G'C$ C w R?."C��. �... � O-'�3 C¢ m �„-� {� � J _ . " C v S� Q V` b i� td .�. . . . - . . . . ` . . � � �`�—" W v..� �� y. K3" � .. + . . . - . .. . ` . 'tT d �',i.�G n.. - . . .. � � � T. ,. . � .. , `` , Q .. . . . . . � � .. . .