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HomeMy WebLinkAbout1611A (9) . . �__ -�,:.,:-��. .WORKERS'COMPENSATIONDECLARATION ��� � � � APPLICATION-FOR�`PLUMBING PERMIT - I here6y affirm thah I have .certificate of.consenf to s If 76A667A - - - - insure;or a cerfificate oF Workers'Compensation Insurance, CE 817(REV.10/61)� ��a o a eertified copy thereof(Sec 3800,�ob.C:). COUNTY OF LOS ANGELES- BUILL��NG ANQ SAFETY �cy ivo. 6084266 Company Gr. American ��� � . , C�rtified-mpy��is hereliy.furnidhed.- �� FORAPPLICANTTOFILLIN�PRINTORTYPE) gUII.DING- �rJ3�.'.�dWISWOOC� RCl. O Certified copy is filed with iFe county building inspeo- — � � ADDRESS � . ,�; . tionCJepallmBnl.� ' . . -. . NUMBER - FI%TUREOR�ITEM � - FEE - � ��-' . -�� � . ' � . LOCALITY :j)1am017C� LidY � Dafe . ?-�'3-`�4APPIiconi . I'edV2Y�Ori . .. .� � WATERCLOSET- . (fi � "� MEAREST � � � � . ----CERTIFICRTE��OF-EXEMPTION FROM WORKERS' � ,,,� sniH�iUe -. � .-�^ Ce055�5T.- - � � � � -- '- �`. COMPENSRTION WSURANCE -�� �� � OWNER - - � ' (This section need noT be completed ii fhe work�imolved by SHOWER ' � . . � � '-.. .- the� armiT�is for one�h�ddred dollars�$100 or lesa. MAll _ _ P � � ) LAVATORY � � ��"'"` ADDRESS . ZOHZ:-$US3,TI258 C`EIIt.�Y�DY. . I certify ihat.in tHe�performpnce-of the work for which rhis - - �- - � �-- . ��� - - � - �� � - permit is�issued,Isholl not employ aoy persan jn a�ny manner SINK �. ��' �" ��T� ZYVl'rie JZ']];.4 TE�."o.g33-21Rq �- � � so a5 fo�bewme sub�ect.to fhe Workers'Compen5ation Laws. DISHWASHER .��^,. ^"' � - . . - CONTRACTOR Date � �� '� -Applimnt-� � ' � � -=�� CtO7HE5WASHER . �,. .•��-�-. . . . . . .. � ,,. P""CE�-TO APPLICANT: If, afte� making ihis CeNificate of� ---- � - ADDRE55 -E ation; you shou{d��become subject fo ihe Workers' � SWIMMINGPOOLRECEPTOR . -- .� - . . Co��i ensation rovisions af ihe Labor Code, ,,, �OTY � TEL.NO. p p yo�mustforih- . .LAWNSPRINKLER.SYSTEM TXVEE� 927�-4 863-1160 w 'ih comply.with such,provisions or this permit sholl.be � � - . � � STAiE�� LIC. - � deemed revokad. wareR HFareR �„ r„ ucENse No. 191969 ciass .LICENSED CONTRACTORS-DECLARAT.ION � - � DISTRICT NQ � P CESSED BY - � I hereby affiPm that I am licensed under provisions of CFaptet 9 � �A5�SY5TEM �"� OUTLETS �_. � (comrYiencing with Sectian 7000)oF Div sion 3 of-ihe Business OUTLETS OVER� �� �� �4�t''� � and Professions Code,and my license�is in full force and effect. 5 Pek SYSTEM � �� � - - �' � f,, >� FiNA� ` VALIDATION � " License Number � �'91'g69- Lic.Class - C36 � "a�cr\.,E�!-b�i1'-'' � r . DATE ���y�'.� . � . . � �2.dU2Y'tOYt - .. FINAI . . � _. � � Co�t�actor Date 2-13-84 eV J � �:❑ i am exempt under Sec� � � � � � � � . � -" . . � . . .. - A.. '��'� � �� B.BP.C.for this reason � � .�� Plan check fee , r i h 1,1 A -9 Datei -� � PWMBING PERM�i ISSU WG-PEE$ � rJ�'"�"� � g � � SignaWre - . - � - 4f�° . - �. c. � � � . . TOTALFEE - � " - - - � -: . _ . .. � . _ ... ��� .f'�� .. . �j� ;.O�.�?� . , _ � . Plan chack applicnnt � - �� � SIIVGLE FAMILY � � j L f��r�>D t: � - HOME OWNER-BUILDER DECLARATION. Name � - - ' - -- ��I by 6ffirm ihat I am exempt from the Contractor's License Address - � � - - � �- --� � � .�:Z��� �"`��= � �- L� ror tlie following.reQson{Section 7031-.5, Business ond � � � . . .. . -Professions-6ode). :. . .. . -- City � � . � - Tel.No. - � � � . � . . .-�: ❑ .I;as owner of ihe proper(y,will do the wark and the � � �.�_ . - . - � . � �. structure�is not intended or offered.for sale (Secfion . � � - . . , � � 7044,-Business and Professions Code). . � . . . . � � � � . � . .. - - EONSTRUCTION LENDWG AGENCY - � . � � � - � � - � � - � - ���� I hereby affirm that tkere is a conshuclion lending agency for .� � - ,- � � - - - � ihe-periormance of ihe work for which this.permi.t�is-issued . . � . � - . -- . (Sec.3097,Civ.C.). - . � � . . . . - _ .. . . . .. . Lender's Name� � � . . . .. � . . .. . � . . . . .. � - Lender's Address. � -� . - � � � - . - - � I certify ihat�I have read this qpplimt on and state�thot the � - � - �- . � .. . � - . � � . - above intormoi�on-is mrrecL I ogree to comply with all County . � �� - � � - - - � � - � - ordinan s and�5fote laws regulating Plumbing,�nd hereby . - . . . _ .. . . . . . .. ` � authori repres � tives of ihis Covnty to enier upon the . � � - � � . --- � � -�- � � � - � � . - �- � - � ---� � ' - above �eMio perty f ' pect on�purposes � � - - � - - . - - - gggr ms , .f��, �� ��_ . SEE REVERSE.POR EXPLANATORY LANGUAGE . . . , :� . .f ` . . . . . . . . .��- . ;., �Signot ie of Parmitiee - - Date � . . � � � - �� ----- --- - - G� Gti q d ��'�1� � v' G� � � - � ��,r�N ����..n � � .� ��. � .... - "%�-G�`,, 'x9 j,��f��14�.,� � � � p,�2 y�� ,4�o\� tx��`\ 2� �` ,v - � � a� �',� ��`� q A�=� � � � � �t o� �� \� � , � � � • � � `.�+ �. � � �Q �,.. s � , � ��� , � _ � . �� � �� � _ � , , � � -� � , � ; �� � � � � ��: � � � � �� �1 �- � � � � �. \ �; ' �, g,, - ; � �� �_ +, � � ` ;" � �� � ,_ �9 � � � �,, � �, �, � � �� ,1 �. ' � � � � ���t � . ` � � lj � � ' � '` �� '� � '� 1 � � o . � � � � � � � i � � ��, ���� � � � �<i � � � �� � � � � , ��14 . - � . � .. 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