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HomeMy WebLinkAbout1610A (9) _ .. .,..,_ ,r_. �-. ,�.-. ., ,- __.� ._._ ___ --- _ - �, _ u.-;..� �,_. . � �� _..- __. ,- d - WORKERS COMPENSATION DECLARATION . APPLICAT�ON FOR.P�UMBING PERMIT � � I-hereb� affum ihat I ha e�certificote of mnseN to self 76A66�A ' � � ,�� insure,or o.cerhficate of Workers'Compensati6n Insurance, CEBrZfREv.70/87) --- -- - - ------ � -- -- -- � - ._ � _.�� or o certified copy�hereof�Sec.3800,L�b.C) . COUNTY OF LOS ANGELES BUILDING AND.SAFETY ' . a k { Policy.No. 5084266 Comoany Gr Amer:ican - � - -� �.. � - � � � �;,�c„�';� �� � � Certified copy.is.hereby furnished. � � . . - - eUI�DING --�� � � � � FOR APPIICANT TO FILL IN(PRINT OR TYPEI � ADDRE55 3543 HaWkW�OCl RCl. �� Certified copy is filed with the�county buildang inspec- NUMBER FI%TUREOR.ITEM -(?? FEE fion department. � LOCALITY D1dTILORCI BdY � � -- � WATERCLOSET . � � /�' �- �- �- Date - �-74—R4 APPlicont Taaz�ar�Fn'n � NEAREST � � —� CROSS 57. CERTIFlCATE OF EXEMPTION FROM WORKERS' ,� AATH iU8 - � ����� .,, . � X, -- � COMPENSATION MSURANCE � � �- � OWNER --� ` -- - . SHOWER - �. . . (This ssc�iart need no1 be completed i!the work involved�by . -- MAIL ZO$Z-BllS1ri2S�S C."8rit@Y DY.�- the perm7-is for-one hundred dollaro(f100)or less.) �IAVATORY - . ..�- '`�'�� ADDRESS _ I certify tFat ui ihe performance of!he work fo which this SiNK � - � - � 3r, pBrm�itisissued,4shpll-notemployanypersort�inany'monner � ,.� ':-� ��TY . ��I'r'Vlne � C�Z']].L� TEL NO.&33—Zi$� .. ' sa as tobecome suhject to.the Wofkers'Compensation Lows. ` pISHW�SHER� - � � � CONTRACTOR ' ' � /'_ Da�e � � �Applicanf - -� � � CLOTHES WASHER ' - aG � ADURE55 � � ... � P �E TO�APPLIfkNT:-It,�-pftet tnaking this'Cerfifimte�of� � SWIMMWGPOOLRECEPTOR : - f pfion,'yau�should become Subjecf to ihe Workers: � CITy ZrU1nP� 9�'714 TEL NO.. $�3_��fjQ �Compensation provisions of ihe Lobor Code,you mustforih- �AWNSPRINKLERSYSTEM � . � with comply with such.provisions'or fhis permif shall be STATE � . . LIC.� ... . . deemed ieJoked, ". � � � � WATER HEATER , /� ;�- ��CENSE NO )]_ (9 C1A55- 3 ��'. -� LICENSEp CON�RACTORS.DECLARATION � � � � �37 DISTRICT NO. P OCESSED BY. ' I Fereby offirm ihat 6om luansed under provisions of Chap�er 9 �GAS SvSTEM� ,�� OUT�ETS - ..--^ � � � � �� .��.-z.r . (or enang with Section 7000)�of Division 3�of ihe Business ( . OUTLEi50VER� � _ ' Z' � S PER SYSTEM. J � - ond Profescibns Code,and my license Is in full fo�ce and effecC FINAL f VALiDATION� � � i; . . . . .� . . . . - DATE �i.,�.�J�� . � . � '�� License Number 191969 � Lic.Closs r��+� - � ,q � � � . . . . � - . FINAL / �� � . - � LeaVerton' 2-13-84 Bv ��i,'` Coniraciar Date . � - . . 6.. - . ❑ . . _ . ... . . . . . ._ .. . - . . . y,y ., -�.I am exempt.under Sec. � -�- e�, x B.&P.C.for ihis�eason . � . . � ► � . �� �" Plan check#ee . Dote: �PLUMBING PERMIT ISSUING FEE$� � �l�� ��-U � � � . - �'� ��`��p - Signature .. _ . � . . . � � TOTAL FEE � .�-� . . . . . � �}c o-o a m? . . � � Plon che[k applimnt . � �'�' G 9�•`�:� � -SINGLE FAMILY � - . � � . � -�� � � - � ��� HOME OWNER-BUILDER DECLARATION Name � -- � � � - " � � � � � � � ^�i�,U��.i��� . - � ' �by affirai that.l am-exempl-{rom ihe Gontroeror's License� - Address� � �� � � � �� � � �J'�.`,7..m 8 t{ . L�... for the following reason(SecHon 7031.5, Bvsi.ness and _ . � � � - Professions Code):-. - . � City . � Tel.No. � . ❑� I,ns o er of tRe proparty,will do the work and the . .. � � � -. � . siruUu e is not�irnended or offered for.sale (Sedion . _ � .._.__ .. --- -�- .�--►� - -. - . � � � � 7044,BuSiness and Professions Code). � � � . �� CONSTRUCTION LENDING AGENCY� . � � -- - � � � � � _ .. .. - - � - -��� � , . I hereby affirm that IheFe is�a consiruction lending agency for . - - � - fhe performance of the work for which(his permit is issued . � � . . � � -� (Sec.3097,Civ.C.). ' �. - - � � Lender's Name . . . . � . � . � . ' � .. . . . - - Lender s Add ass. .. � � . ... . . . . . . .. .. ... . . . . �� � � ::. I e t�?•y tha I hdve read this�pplimtion and stale thai the . . . - .. . . ��� - . . . . - - - - . - - above infarmat on-is correct.I agree ro wmply wiih all County . � . o dino es and.State lo,vs raguloting Plum6ing,.ond heraby - . � . . - . aufhor'k repre n atives of�ihls Co nty ro enter upon the � � � - . . . � � � abov 5»ention ope fy nspecfion purposes. - - . . � 7� �`l SEE REVERSE POR EXPLANATORY LANGUAGE � .��,�-���� �/3_ � Signature of Permlflee Date� � � , - . . �� �� - � � _ — � - . ��, � �,,��o �� � �� � � �,_� � ����� �1 � � � � � ; �n�� � m��'�;� �iv�� _�... ' 9 ,a �+ � y Z�Z�G 4�fi . ��3 �� �"�.U3 ��b.. � � � 1� �, - �. F a � �O � � � � ���, ` G G"� , ��� �p� ��v� �E. 0 ° `�, \ � m \ . ' � . . � ' �� . . . ��� �� { . � .. . . . . .. � . �;� � . + � .. . � ' � � . � \ �'�m � . ... -� . � . . . . $ � . . �w . �� � . � , �`k O , . � . 't ` - __ � � . . _ � � �. 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