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HomeMy WebLinkAbout1607A "'°RKERS'`°"'PE"S�"°"°E`�R"T'°""- APPLICATIOM FOR PLUMBING PERMIT � � I hereby affirm iRat t have-a rerirf cate of conseni_toself :�gq��q. . . . nsure;�or a certifimie of Workers'Comperisahon hisurante, -�CE el7(REV:10iE1) -�-- -��- -� �-- - � - - � � -� o a cerhfied copy lhereot(Sec_380D,Lab-'C) - . - . _ _._-. ____.. _COUNTY AF LOS ANGELES BUIEU►NGANo-SAFEFY �cy No. 6084266 Company Gr.. Amerioan 4 CerPified copy is hereby-furmshed ��.��' <�c7� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING - � � � � �r -Certified copy is f'led wifki ihe county�bu7ding'inspeo- � . ADDRE55- � � fion deparimeni - -� �- -�NUM1ASER--- ----FIXNREORITEM� -- -C - - FEE � � � �ate��� 2-]-3-84 Appl cant Z+edVPI'�6Y1 � -� - � WATERCLOSET. ._ ���LITY� D�.1mUxqa-BdY' - , .� . � -- ' ��-- NEAREST. � .,� � - CERTIFICATE OF EXEMPTLON FROM WORKERS' - . _3�_ -RATH TUs_- -. - �..+�CRO55 ST. � . �. � � . -._ - COMPENSAiION MSURANCE� - . .. � -- . .. . .. . --.:-.- -�WniER - � '`. '...'.. . . .. ..... (This settion need�nof 6e completed ii ihe work irtVolded by - '�'�ti�E�` � - � - POY1C22ZOSd HtrIt1E5- - - the permft is for one hundred dollcrs(�100)-or less.) � /' -invniORY �- .� __.�;��. MA�� �- � . ��� � " ADDRE55 • I certify.thaT in the�perfarmance of th�wa�k for which ihis- � . . � � � � permit is issued,i shcrll noi employ pny person�n qny manner � SMK - � � �/J ��TY ICV1112�. 92.714 TEL NO.�833�-21$Q �. so cs to�become sub�ed to the-Workers'Go.mpensation.Caws.. �- . -- j - . ----- .------ --.--�--. ___ ___ .__.__.. _- _—_._ __. � - � � .. .. Df5HWA5HER ..�/�J----°' CONTRACTOR ' � - � � Leaverton Bros. Znc. Dafe -- -- Applicani�- �� CLOTHES WASHER �_ ADDR€55 P' "CE--TO APPL7CANT If, trHer mak�ng:tli s Cerhfica}e of -� � �- - , �.i H .1- -- -- _ t ption, you should become'subject to 1he Workers' �-5WIMMING POOL RECEPTOR��- � -- -- --- - ' - ` - - Com ensation - - � - - - QTY ' TEL.N0. - p provisions ofthe��ta6arCoda;you musi-fOrifl- � �AWNSPRINKLERSVSTEM � ' � ' _� � - wifh-c6mply witH-such prov-isibns w 14is>pe�mif sholl be S7ATE - � � ��� - ; deemed revoked. Wntee Hetiiek � --,� uCeNSe No. �.91969 C�ASS C36 - LICENSED CONTRACTORS DEC6ARATION � � � DISTRIC7 NO. PR ESSED BY �� �hereby affirm ihpi I am IicenSed under provisions of Chapter 9 � GA55VSTEM �,j OU7LeT5 -(�.,�,ro " � - . � . - � J � (tommenCing w'ih Secton 7000}_of D�vision�3 of the Business OUTLETSOVER- - �� ,�-P-2��-�.�y and Professions Code,and my license is in fu�l force and-effect �- S PER SVSTEM� - � � � � � 1.91969 C36 _ �a ��y�-- �v �"' DA E� �'" p�t/��'"/� VALIDATION � License Number L c.Glass � conrracror i,c�asrartnn �. .�Dore 2-,,.��$.4� - . - � BY AL���'� . � '� � . . . � F��9 _❑ I am exempt under Sec. - - � . � .,, „! B.&P.0 forlfiisreason � � � - � - �' Plan check fee � , - DaYe: . � . . � . �' - ��PLUMBING PERMIT ISSl11NG FEE$� � ��l ^'"�) �� � .Signafure � � - - - - . � _ . � , . . - � TOTAC FEE � � (,��,+e �� � - - e'� fi Q,`%�,A � - - Plah check applicanf � � - � f}p.y�':.� � �;c�'. . -� - � SINGLE FAMILY- � � � � HOME OWNER BUILDER DECLARATION Name _ -_- _ ����.�� . f by�aff rm that:l am exempt'from rhe�Contractor's Llcense qddre4s - � -� ' Lu. far fhe following reason(SEction 7D3L5,Bus�ness and . e .���h,�Q u �-�� Professions Code): � Cif � - � � �� - � ❑ . � y Tel.No. � . � ���I,os owner bf ihe property,will do ihe work and Ohe . . � ',�,�.� �"•�/J. � �, structure is naf intended or offered for sale (Sedion � - - - � � �, � - � � � 7044,$usine5s and Professions Code): - � � . � . � - - -� � � - � �- � �� -�- � � . �;: . . . . .. . � . . . . CONSTRUCTION LENQING AGENCY - .. . . �. �� I hereby atfirm ihot there is a consh�ucPion lending ctgency for - - � � � r'; ihe-performance of(he-work foc which ihis permit is issued . .. . .. . . � � � - I'��. (Sec 3097,Civ.C.).�- � - . . - � � . ��` Lender's Name . . � � � � .. . � � � ���� Lender's:Address � - � . �� - - I cenify}hot I�hove read�his applicqtion ond stote that the . - . ► � . �. - - above information is.correct.I agree io comply with all County . -. �� � - � , � . � ordinances and StBte laws-reg�ulot'ng Plumbing,ond hereby � . _ author�e repres,era-dt ves of ihis County to eNer upon ihe � � � � - � � -� � . � _ abov enhor� � �operty for inspecfion purp ses � � . . � � - - . � � ^ � � ' SEE REVERSE FOR fXPIANATORY LANGUAGE - � / ,��'c�- �����,G�� �-/�i—a��� SignatureafPermiitee . - --Date - �� - � � - . � � - � ,._.. - . .. t . ` . , . ��� . � � . . �. .-- - � .�}:� . . � . 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