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HomeMy WebLinkAbout1618A (9) -�. -:- � = _ . --- =--___ -- _ -- -_- -- - _-- _ _ , �WORKER3'COMPENSATION DECLARl4TION - � � APPLICATION FOR P�LUMBING PERMIT - I hereby_affirm ihpt I f�ave a certificate of consent ro self 76Aa67A � � ,��, insure,or a certifica�e of Workers'Com ensalion�lnsurance, � � 9 P CEBl7��(REV.10/81-) --� �— �- - . . . . - . ' . . �G , or a cerirfied copy thereof(Sec 3800,tab.C.) GOUNTY OF LOS ANGELES BUILDING AND SAFETY �cyNo: 6084266 comPa�y Grb American , r�- Certified eopy�is hereby fur�ished. ��� � � FOR APPLICANT TO RLL IN(PRINT OR TVPE) BUILDING� - - - �,Cer�ified copy.is filed�with ihe munty building inspec- � - ADDRESS 3 - fion depariment. � , . - NUMBER- - �FIXTUkE OR ITEM ��@ FEE . - � . � . � LOCALITY .. .. Date 2—�-3-84 qppli4anf � ��'eaV@Y�tOtl � UVATERCLOSET. � f NEAREST _ . . . . . � CRO55 ST. �' - � CERTIFICATE-OF EXEMPTION FROM WORKERS'�� � BATH TUe - . � �.,. r+ � � �� � - `� . . .; . . . ._ . ... - COMPENSATION INSURANCE � � SHOWER � � -� �/f, _�.,. OWNER.- pOF1L3�:Y'OSc'�, FfOIIleS �- � - (This secfion need no�be completed i{fhe-work involved by � ��� � �the permit Is for Qne hundrad dollnB(5100)or less.} LqVq7pgy � � ,,:� " qDORESS � I-cerhfy�ihai In ihe performqnce of�ihe work for which this . _ . . - . � . ermif is issued,I sho��noYem lo pn erson in an mqnner SINK � - CITY .� � � TEL.NO. P P Y YP Y . .. . . .a� H33-2]_$O - so os�o-become subjeci to fhe Workers'Compensaiion Laws. DISHWASHER � � � �- - - - - � - � � - �' CONTRACTOR �averton�Bros., I]1Cs � Date � � �.4pplicant� �� � � �CLOTHES WASHER .�- - � "'�'o- � � .� �� N^TICE TO APPLICANT: If, attpr making this Certificate af - - � � ADDRE55 i672�1.Ha.�.Q. . ��- F ation, ya� should��become subject to fhe Workers' SWIMMINGPOOLRECEPTOR . � � �� � .. CITY -.: ..� . ' TEL NO. -�'� C._,penshiion provisiohs of the Labor Code,you�must forth- LAWN SPRINKLER SYSTEM ' — with �amply with�such--prov sivn5 or thi5-permit shall be -- -- STATE - �OC. ` deemed revoked. - �� � � WA7ER HEATER . - � - LICENSE NO--- -' "-"- C1A55 ' "'� �LICENSED CONTRACTORS DECLARA710N - � � - - ° �� DISTRICT NO. P CESSE�BY � � � - ,,� I hare6y affirm ihot I am licensPd vnder provisions of Chapter 9 GAS SVSTFM��� �OUTLE7'S . •� � . " � � ,}-_ . �,G''.. �,.Yt�.F,s..�� - �--�(commencing wrfh Settion 7900)of Division 3 of 1he Business -0U7LETSOVER - � � � �o� and Professians Code,and my license is in�full farce and effeci. � 5 PER-SYSTEM� � � FINAL r �,y�L �//���DA'�ION �' � Lice�nse Number 191J69. Lie.Class C3( � � -f"""� DATE �/�7�O 7 . � Leaverton 2-13-84 ev �' � � Contracfor Date FINAL y'].�l/�J�� � . �''' f:' ,. ❑ . .� . � . ... . . . � . . . &8 `��. I am exemp4under Sec. ��- -'�� , . �13 ; . . . . . . � - � _'. Sd9 " B.&R.C.for this reason � . P�an ChBck fBB � - . -�'� �'i j,c°�.{� � Date: . . �� . � ��- - - � � - - - 'PLUM8ING PERMIT ISSUING FEE$ .:�(? �'�U ► � � ;4 c m �, E �,� . . Sfgnatura .___ _ � . _.. . �,r� ,9 _ . . . . . .: . . . . . � TOTAL FEE � FJ�j �Gr .. . . 1 `; � U�,��.l.l � Plan check applimni � � � �SINGLE FAMILV . � - - � �� � . . . . . - . �.t;ih J t'.'1�: 'HOME OWNER-BUILDER D6CLARATION - - Name � � � - - - � I' by offirm that,l am exempt from ihe Controctor's License - � � - - - � -_�u'�-�7`'`'�LI. � L. or ihe following reason(Section 70315, Business and Address - � � � . - -�- - . � Protessions Code): . � � . - � � _ . ❑ .. . . . . ,�City Tel.No. . . . . . _ . . . I,.as owner ot ihe property,will do ihe work and the . . . . . . . � - structure is not i fended or offereo'for sale�(Section � � � - . . � - � -:-� � � , - '' . - - _ � - - 7044,-Business and Professions Code). - � � � � � . - � � , � CONSTRUCTION LENDING AGENCY � � . � .� _ �. � � - � I hereby offirm ihat there is a construction lending agency for � �.-- � -�� -�- � -� . - � . � - - - the per�formance of fhe work for wnich this permi�is issued � -- �- � . � - . (Sec 3097,Civ.C.).. . . �. . � � - - . � . . . . . . Lender's Nome - . � . . . . . .. � . .. � . _ Lender's Address- - � � - - . � � � �--� � - - � � _ I certify ihot I have read this applimfion and state that ihe � -� _, . � _ ab ve information is correct.I agree to comply with all County � - � �� � � � � - - � - � � - - ordinonces ond�State Iaws regu�aling Plumbing,and hereby . � � � _ � � . � abovo 1z entior ed'. �.�er��spe�t on por���on the - SEE REVERSE FOR EXPLANATORY LANGUAGE...---._.. �.�.. .. .-�. �. . . � �... � � .� � �I�'� ! .�-I..l'i.� �� / � . - - � . . . . -Signature of Permiitee � - �Date � � - - � -� - . � ' _ . . . �,Z �C�',.� '' b .:. � � � � � � � � .� ��'�•• ..s Y' G i 2 c!i V - z,Z Z a ��a_ '� � �°'ya-� y � ., y� �- -L .� 'Z a^ `` .��� rz.0� . ,. � _'m�, O �� � � O Y �° �X� `n �G� � a`�t, � �. . ,_ ..��y . �� �� � . - . . -. . . 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