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HomeMy WebLinkAbout1619A � - . WORKERS'.COMPENSATION DEGLARATION � � APPLICATION FOR�RLUMBI�NG PERMIT � � � � ! I here6y affirm ihat I have a-certificate of conseN to self 76A667A insure,ora cerfificote of Workers'Compensa�ion Insurance, CE 817(REV.10/81) � � � � . � ... � �. � � or o cert'rfied copy_thereof-(Sec 3800,Lab.C.)_ COUNTY OF LO$ANGELES BUIL ING ANU-SAFETY P❑oI cy No tioSta9F6 company cr A�rican Certified cqpy is.hereby.fu sh d ����� - - - � FOR APPLICANT TO FILL IN(PkINT OR TVPE) � BUILDING ❑X Certified copy rs�filed with��he county�6mlding mspec- . ADDRE55 3542 Hawkwood Road � -� --fion-depor�ment:- - - - � ��- �. ' .NUMBEft - HXTl1REORITEM �rd FEE �OCALITV� - Dare 2-13-84 Applicani Leaverton � wa�eaos�r — '' NEAREST r �CERTIFiCATEOFEXfMP710NFROMWORKERS'. t� gATHiue � � .- �. � CeOSSSi. - -- � � t - �-�' - COMRENSATION INSURANEE- - � ��� ----'— -- — oWNER ppnaer0$$ HOritBS'�� � - � (Th(s section�need not he compleled.ji the work involv2d liy SHOWER � - .,. . the permit�isfor one hundred dollars(5100)or less.) wvnToev � � -" aoneess. 2082 Business Center Dr. - �I ce.tify-ifiai in fhe performance of fhe work��for which this . � � � - - � . . �-�- - ��- � - - - .. i, permii is isSued,�l shall noi employ any person in any manner � ��NK � - � CITV�. - TEL.NO. so.as.to-:becomesub{ectlothe.Workees CampensationLaws. - F� � V.�: 2 �14 �33-2�:8 _ - , . . DISHWASHER ��r� CONTRACTOR� . � Date Applicanf� � �� � CLOTHES WASHER � � � "� qDDRE55 - � N�'T�CE TO APPLICANi:-If, aFter-mdking fhis-CerYificate of - --�- � �� . � a-672'3' H`i'�-e -. .. .. � E �tion�; you should�become Subject fo fhe Workers' - SWIMMINGPOOLRECEPTOR - . � � -G.. ensaFion rovisionsof the Labor Code, ou roustforfh- - - CITY . ��VlC12o 927I4 TE�."o. �g63-1160 P p Y LAWNSPRINKLERSYSTEM .. - w�ih comply-wifh sucfi-proJisions or this�permit�ihall be STATE � � _ LIC.- .dee:riec�.revoked... - - �WATER HEATER � LICENSE NO,._ . � CLAS$-� �� � �` ' i�ICENSEO-CONTRACTORS�OECLARATION: ' . . ' - ^.�• DISTRIQ.NO- - P OCESSEDeY .�� . ; .. I here6y.afficm thai I om licensed-under provisions.of Chapter9 GA55YSTEM ,,,�' 'OUiI;E75 � �-�� -^�'� � ��� - � � � � �al.Fz€.G�.✓ (cpmmenring wifh$ec�ion�000)of Division 3 of fhe Business OUTLETSOVER W .� . . - - --�. . -� and Profesgions Code;and my Ikense is in full force and effecL � 5 PER�5YS7EM - �FINAL ` � � � �� � �� /�� /�„�` VALIDATION � i . . ��. . � DATf d � /` �. License Num6er 197,969 Lic.Class C3Fi�� . P � - - . ..._ - . .'�� . . FINAL � ,n, . �`� ,. Leaverton 2-14-84 gY t;i���`�` � Confractor Dafe � � . � ❑. I am exempt under Sec. - � �� . . . . � �y , _ � , B&P.C.for ihis reason � � � � '�� --- Plan check fee `�' j � Date: . . ___ .. ._ . .�► . � � F.�0.�.� .'" PLUMBING PERMIT ISSUING FEE$ � .,�'� , � r;u m m m� Signature � - " °. �: . . � . . . . . � TOTAL FEE � . `�"",�. . - . .. `: _ _ . P � 1 0fi,�C� � -� � - � � Plan check applimnf - - - � � - � - . � SINC�LE�FAMICV � � m �-�{A�'�,,t^�� - - -HOME-OWNER-BUILDER DECLARATION �Name - � - � - � � - - . _ - . � - � � I' �by affirm ihat I om exempt from the Contractar's License . . .. : 3�,�� `1��j� L. .or�tha fallowing reason_(Section 70315, B�siness-and �Address� . - . � � ;,., Professions Code): - � � - City Tel.No. � � � - � � ❑ I,�as owner of the properry,will do the work and the � . -- . .� . � � � - � � - structure is not intended or offered for sale-(Section ' � - � - � � .. - � . . 7044,Business�and Professions�Cbde). - . - - . . � � - - � � � CONSTRUCTION�LENDING AGENCY . - � . . . . .. . . � . . . . I hereby affirm ihat there is a-.conshuclion lending agency for -� - � � - � - - -- the performance of fhe work for which this.permit is issued -- - . � . . (Sec 3097,Civ.C.). � � - . . .. _ . .. _ . . _ - ;,;. Lender's Name � _ . .. . _ - - � - - iender's Address - - � . . _. :..� I cerify ihot I have read this application and state ihat ihe � . - - � � � . __ . : . . - - .abo- �nformoiion is cotrect.I agree to comply wiih all County . . - � ordinances and Siaie laws regUlafing Plum6ing,and hereby . . . - . . -.-�'I . ❑ul-orize repr sentatives oi ihis-County to enier upon ihe . � � � - - - � � - --- -- �� � �� -�� � ve-merIio _,property for inspection purposes.. � . � - SEE REVERSE FOR EXPLANATORY LANGUAGE �� � �';f� ig ature f Permittee � Date �- � - � - - c s��'y p � o .. . -. .. � .� � C p N � 4 � . . . . '��� �� � ��?�.� �G Ps+�-'0,,.� � �O .. N� � � � ��,� � 'ZI'�, r.._ 'wj' '6 ps 1 . � ' M� . � `� � � � W � a � �� a � � � � � fl � � � � � � , < i r �� o ` � � ' � � t 1 � Uy y: . . �:-� . , .. _ - . . . � . � � R"� �' �Ct . . . � � � � . ..� �� � . . �. � -� �... ,�. � Z. �. . � . ����. . . . . . . - � � . �, � � � t� 1 � � f �.. . 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