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HomeMy WebLinkAbout1263A (6) ? WORKERS'COMPENSATION DECLARATION � qppLI�ATION FOR PLl1AABIN� PER�'T _ ° I hu.u4.V Ulilf„m, lFnf I V.�ye;; -t=rfi{irn!= n<, cvi�5v'-�+'�i=i` 2C-JUEn GF°:'v^I' �� � . inscre, or a certificate of Workers'Comoensation Insurance, 76A667A v v . � � or o cerrifie copy the�eof jSec.3800,,,7Q6.C) � CQUNTY OF lOS ANGELES DEPT,pF PUBlIC WqRKS � . P�olicy No � � Company 49�i r. '�� . � . g U Certified mpy is hereby fumished. - � � 9 �^t p fOR APPLICANT TO fILL IN(PRINT OR TYPE) ADDRESS ��` � �' (�l� I��£� Certified copy is filed with the couMy building insper � � �ti�de arimenf: � NUMBER FIXTURE OR ITEM � FEE �OCALITY - ^ � Da�e ��- Applicant � ����A� � WA7ER ClOSET NEAREST � f� 6E @[CkTE OF EX£fa1PFfON r"ROA4 WORKERS' �AlH tu6 _ CRO55 ST. ^� _ �� CQAhPENSATION WSURANCE OWNER ``• (This section need nof be eompleted J£the work involved by SHOweR ` " MAIL f the permlt is�for one-h�ndred dollars(5100)or less.) � t.4vAioev _ aDoaess � � I cerfifv that in the performance of the work for wFich this permif is issued,I shall not employ any person in ony manner SINK � CITY tEL NO. _..._.,.. ' —_...__._ __._ . i so as fo 6emme subject to f e Workers Compensaiion Lows. DISHWASHER � �' � i CONTRACTOR 4 � Ddfe Applicanf CIpTHES WASHER qppRE55� `h $� f� `' NOTtCE TO APPLICANT: !f,,akr,r making ihis Certificate of - i ��!,(.�.�.�i.�r�� StiJiMMING POO:RECEFTOft ^7 a fzemption, you si�ouid necorne subjeci ra the Workers' GTY " � `�� tEL N �(.� i Compensa?ion provisions of fhela6oc Code,you must forth- LAWNSPRMKIE&SYSTEM � `�"' � � with comply with such provisions or this perm4l shall be STA7E . ry .t, IIC. �- � deemed reval;ed. WATER HEATER L�CENSE NO. ' t� f CLASS .7� IICENSE�CONTRACTORS pECIARATION � D�sT•RiCr NO. PROCEsSEo sv r GAS SYSTEM OUTLETS �, � � � i hereby off�mthati am licensed i,.nder�provisions of Chaprer4 �� ^- � (commencmg with Sectron 7W0)of Div"rsion 3 of�the Business - I OUTLFTSOvek --- ��F � r � aad Professions Code ard m license i,in f�il 4orce and effed 5 P&Q SvSTEM 'y? ; .- .y.rY� �� �- — fINAL � .5- !/ALi6dT10N 3}„ y � DATE ,� � .�. } License Number� _ � Lic.Class � � : � t�. ..��+p� � FINAI ��� Contractor___,�:�'�'✓��.�Dore__����1�;�� 8Y �p"y� �� � ❑ 7 am exempt under Sec `_ —!'"' � "� � _ � � 8.&P.C.for this reason —I Plan check fee � �'i' � _ Date: �'-"'—"" PLUMBING�ERMIT lSSUING FEE$ �s„� ��� . �- Signafura . �.._ -RA ,- � %�J,v%�, . � � TOTAL FEE �/` F;"��� y �Plnn check appiicant �0 e g. SINGLE FAA11l� . � . � HOME OWPJER-BUIIDER DECLARATlON Name-� j s � ��!' � I hereby affirm Ihoi!am exempt from the Controctor's License „ a � Law for ihe follawing reoson (Section 7031.5, Business ond �Address � � - � ts���u �' ProfewionsCode): �Cit Tel.No.�'j � ,C � ?� ❑ L_._.Y_._ ���� I I.."3 _.� �4.v� _.A R . I,os owner ai ihe property,will do the work and the � sirutture is not intended or nffered fof sale (Section o^- ` - � . 7044,Business and Professions Code). r�'(�`,�; '�� ` � CONSTRUCTION lENDWG AGENCY p� -� I hereby affirm that fhere is o construction lending agency!o1 L� the performance of the work for which this permit is issued . � (Sec 3097,Civ.C.). ... Lender's Nome Lender's Address � � . I ceriify ihat I have read this opplication and siafe thai ihe � above informotion is correct.I egree to comply v,+ith oll County . ordinances and State laws�eg�lating Plumbing,and hereby authorize repre�5,entaiives of this County to enier upon ihe . ov ti Re�d properry for inspection purposea � SEE REVERSE FOR EXPLANATORY LANGUAGE �. �r � Sio _.urR o'f ermittee � Da,e � s s . A„, � r'7, .,.°?„""� t °(` -.on S r _.... 7 �,^ ' :yt 3 1 j' 'i. k g rv z i � p ; � ( . . � � :� � : j 3 � € l € � � � j � _. 1 � �5 j � 3'�� � � ] 3 j � �t'�s }`?�� E t � �{ � � � � � � 3 t � . ... .. . 5 J � 3 � /"� ��) C�g E Fi . 3 � � j 1 � � i g r. t � d t ': { } E� € d � E € � € � t � � � � € -r�. � � � �' . 8 � � � � � � � � € � � � � ', 9 � ,' ' E l i � � � � � � � � � � �� � �. j � � d � � � � � � � � � ��.._� �._rr�� �. �.� � � `�' �� : I � j � � � ' ; ;�� � I � ��'V � � � :� ' ? � � e ' € Y � ��3� i F� ' ' :"� i ' i � ' ( ( 1 ( 1 � �] � � ; ( ` � � j " ;,-'� (�.�i s � i � � ? 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