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HomeMy WebLinkAbout1322A (7) WORKERS'COMPENSATION�ECIARATiON ��p"�QY'�N FIrOR PI I IM�IN� PER7V'�T n 1 here6y affrtm ihai I have a ceriificate of consenl to salf 20-0026�PW 6/87 - �'� insure,or o certifimfe of Workers'Compensafion insurance, 76A6S7A : �) o��cer��f�ed capy�he�eof(r5ec 3800,lab.C.) COUNTY OF LOS ANGELES DEQT.OF PU�LIC WORKS �� ; Polity No. Company � � . ; � Certifled copy is hereby fumished. � _ FOR APFLICANT TO FILL IN�PRINT OR TVPE) 6UIL�ING y y ^G� � } ADORESS d �� e Ceriified copy is filed with the coonty building inspeo- fion deparlmeni. NUMBERT FiXTUREOR ITEM C FEE LOCALITY � � 5 � WATER CLOSET � Date _Appliconi NEARESt � CERTIFICA7E OP EXEMPTiOA!PROh4 WORKERS' BA7H TUB CROSS Si. -�� �G��a,C�.'�. � COMPENSATION INSURANCE - ' SHCWER OWNER ���� �^ �/� (ihis�section need no9 be campleted if the work Involved by MA�� �. .the.permit is.for one hyndred dollars($140}or less.) �avaroRv � � A�DRESS ��°-C'.� � 7 certify iha}in the performance of the work for which}hi; � permit is iss�ed,I shall nof empioy any person in any manner S�NK c�iv ?EL.NO. � ,.-" so as to become subject io ihe Workers'Compensation Laws. oiStiwaShiER CONTRACTOR � �Upte�j 1�;��' AppliCattt�e3t.� _��� CLOTHES NASHER AD�RESS A � � N0710E TO APPLICRNT: if, afi�r making rh3s Ge;tiflcats o4 �5w�r�nmiN�voo�eececroa � ����� « Exemption, you should become su6jed to the Workers' Cnm en5afion roWsions of lhe�iabor Code, ou must forih- CITY TEL NO. . p P y LAWNSPRINKLfR5Y5TEM � with comply wiih such orovisions or ihis oermit shall be a STATE LiC - .' deemad revokad. � q WATER HEATER LICENSE NO. CLASS , � CICENSEO CfJNTR6,CTfJRS DECeARAT!ON � DI57RICT NO. ?ROCESSfD BY � I here6y offirrn Ihot i am licensed'under provisiens of Chapter 9 � GAS SYSTEM OUTtE75 Q (f f` � . � I C. � (commen;ing with Szction 7(XXi)ot 6ivision 3 of tFa Susiness p OUT�ETS OVeR � --- ¢A nnd Prafessinns Code,and my license is in'uli torce and effect 5 aee SvstEnn F(NAt V LtdATION Ce�� � � DATE j License Number _Lic Class � j:�;� � FINAL ,.��_�: Coniroctor Date gY � ��� � ❑ I am exempt under Sec.� ��'- � B.&P.C.for this reason �-- � �Plan che k fee :fl. �3ate: `�'� � s PLUMBWG PERMlT ISSUING FEE$ � ta Q �� Signature - . '}- � .. � TOTAIf-EE � � Pia�check applicant r---^"-'"„�'..`"A Sit�GIE FAMII'f .$.id,,,�,,,,�,� � HOME OWNER-BUILDER DECLARATION Name - - �j 1 hereby affirm that 1 am exempt from the Comractor's License Address ��""' - """ � � Law for the fallowing reason (Secfion 7031.5, Business and � - . Professions Code)� City Tel.No.:___.,a-= � '�'"� I,as owner of ihe property,will do ihe work and ihe � �� �r°`�Fj � . � strucWre is not intended or offered for sale (Section ► � _ a v - 7044,8usiness and Professians Code). � �� � �ONSTRUC710N IENDMG AGENCY I � � �I ���:! � � � I hereby affirm thot there is a wnsfrucfion lending agency for - � ;, �'%�-= �� G...�,..o' . � ihe performance of ihe work for which this permit is iss�ed . - � . 1 (Sec.3D97,Civ.C.). �j���--�1,� �- i � � Lender's Name �. - 3 lender's Address 1 certify thm I have read this apqlimtion and state that the � �� - above informa�ion is correct.I agree io comply wiih al!County � � � � ordinances ond State laws reguloting Plumbiny,and here6y � -. �. ; 4 authorize iepresentatives of ihis County to enter upon the , . � abo�e- n�ioned�rape�inspecrion pu�poses. SEE REVERSE FOR EX9lANATORY LANGUAGE '.� -' '�Signature of Permittee Da�e �- �.� � � �,. _ . :qi,�, � . 1 � w �,,,„„�,,,�.,s � � �� I � t € - �a� r 3� i s � � .�1 t : S *� � � 3 � �: � i 9 _ x ; � j� t i � �, ` 1� ( f � � y} E � . E �r §���ir ��� �.� � � { d ; . � { � � � � � ��x e%� � srt�, g, , � � � ; � f � � � , y d �z _�E,r. t � 3 ` � � � � � i. � � S !j ��'..) � � .� �t' t � � � � j( � � � i � S �' ��€ i ��i� � � � } 3 � � � � i ` f � F € � i 8 s i � ; � j ��`� F €y . ���. - � $ � : i � � ] �......... -_� � �' "� � � � 3 � � � I c,�a� � j y ( t. i..... � � q � � � � { � ; i�� �� � � � � ' `�S s � ' ! ���. € � ( t � � � �' - � � € � . E � � � C ? 1' i i � s ; 9 3�� , , }� , ; 3 ( � 3 ,fb 3 � � i�ry .._..-�__.... � : ` � � � � � � � � � i ���� � . � .....�`�' � ��,a � E � � 5 3 � f 3 f .`.._..��...�...i M � y�_ � E � ( tT7 � ` � � � ? � } f ( I �� ! �� � � � � � . E �' E � t I' � ��� � F � 3 � . � � �i �� � � � ' _ ? � $ � � , � � � � ;. � �_ � � � ��� E � � � � s � � � �� i � � � � � � ! � � � � � g ? � � ' ��� � � F � � � � �,.�.,,:.���,n.,.�,�, ,�.,��„�,.�.� �,�,� � � � � � � j � � � �' ( � � ; � � ` � I � � , � ( ;5 � ` � � ( � �..° � i ; i j � , F §¢ 3 � ( � ! ( . e � � < 1j < 1 I � E, � € � t � � � € ( � I( ... � _ '{ � t } "' . ) � i � � �3 � �9 I � 3 � � i ¢ . ( ' I � { # 1��_.. i � ( E � j � 1 I � � � � � � i � ! � � � � � � t � � � � � � � ` C � ! � � � � ' ` � � � � � � 3 � ' � i � � 3 � i � ' � ! � � � � � � � � G , � � � , I , � � � � � � � � ; ` i � ; ; ' � (( ; �� � � € � � �. � � 1 ] '., i � ([ f ;� � � @ � E � � i � �' � � E � =i�1� � { � � � � �3 ��� � � } � � � 3 3 � I I ���: y � I � 3i � 4 ' j �37 i : I ! 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