HomeMy WebLinkAbout1236A (6) _ WORKk:RS'COMP�NSA'CION DECLARATION ]6A66]A Q�p' ��^�T 0 n N F�R P�t ��p�N G �9 G R 1�1' 1 ,�g
. ` �;y a7firm ins: : :.a�.c a cc;:�:icaic oi conset¢ iu seii "s:�(raoj ' " , _ ' �] r "'s iI �
rnsure,or a cert�ticate of Workers'Compensflfion lnsurance,or ��i
� �1
; a certieiea copy thereof(sec ssoo,:,a6.[.) COUNTY OF LQS ANGELES BUI IDtNG AN D S A F E T Y
' Po;icy N6!�C Q�mpany�EIL.4���� � .
i
'� ❑ CaHified copy is hereby(urnis2�ed. � �M - FOR APPLICANT TO FIIL{N(PR�NT OR TYPE) 6UILDING // {^.��z �
� Cerlified co NUMBER F�XTUi7E OR ITEM e FEE 'QDDRESS���� � �((L>j�-� !/n� _- �
� py is ftled with r e county bui in 'nspe n /� 7
p����� ✓ � �WATER CLOSET LOCALITV �,f,,,t�/ .. p�!1 �f;�'��
� Date Applicant IVEAREST �rV i a l�la J��
i
'BATH TUe � CHOSS ST. __ -� �,�
�' CF:RTIFICATE OF EXbb7PT[O;V PROM WO12K's iS' �� -
-__ __.
j CUMYY.NSA'I�IONINSURANCE SHOweR OWNER . ._ -.
LAVATORY ! MAIL �-.
(This section nr.ed not be eompleted if the woik involved 1 i aooRess '����
by tne permii is ioi one hundred doiiars t$i�6} or iexs.j 'stNK I � �
CITV TEL NO. 6� -
r
i certify that(n the performance of the work for wfi�ich this �' 61SHWASHER �
� � � � � �� CONTRACTOF� � � -
perm�t�s is5ued,I�hall not emp(oy any person m any manner „ .._.__ _.._..._- � ' / -•� �
So as to beCome Subject to the Worker�'(:ompen5atlon LaWs. ' CI.OTHES WASHER � � � t� '
� .. ADDRESSI�-�j J r6 d v��. - y- ...
Date Applica�t ' . --_-_ ___r.L�v � �
-SV�IMMiNG PCQL RECEPTOR�
NOTICE TO AYYL(CAN'i' [f,a}�er mxking thls Certificate of CITY 1 ,J��l�`f��✓� TEL.NO�_' .,-� 5.2�-
Ezemption, you should become subject to the Workers' LAWNSPRINKLERSYSTEM �<='� — �
� I STATE �''y LIC. s- ,,_„ �'� �
� Compensati�n nrcvlsions o"fhe 1.ahor Code,you must forth- � LI-CENSE NO.r,[L _�_ CLASS�- 6_..-"� � ,
. �vith cnmply with such provisions or this permit shall be WAYt�HEATER I
` deemedrevoke@.� — ..� _ ._.._----_�._._..
�----" � �, ` OISTRICT NO. PROCESSE�BY
y .GASSYSTEM �UTLETS � ' �J �f �- �/
a LICENSEDCOATTRACTORSDECLARATION �pUTLETSOVER � C_-�"" ���CI-L '✓'
I herebe afflrni iiiat I a�n iicensed under pxovisione of Chapter �6 PEFt SYSFEM � �� -���- �-
; 9 (enmmencing with Sectiu��7�00)of nivision 3 of thz Busi- � FiNAL VALIDATIOR -
� ness 2nd Professions Cude,and my license is ir,full force and DATE _
eft'ecf.
License N�mheP�1 �p Lic.�Class +`--��� �� . - � gy - �
� Confractoe��1���� �J Date �'-!�'�r�� _ - � _
� ❑ ��. -
i am ezempt from the I�censing iequ¢emenis as i arn a Plan check fee
licensed m�ClSifeC4 oi n t¢g:s4eted pmfessional enginer.r pLUMBlNG PER[NiT lSSUING FEE$ � --� -� .
� i
� aciing in mV pro�essional capac�ty(Sectinn 7051, Bus- _ �
� ine,cs and Professiuri5 C:ndz). TOTAL FEE �� ��j - �
Lic.�r Reg.No. Datc .� Plan check applicant -
t ' _.- t ti.A (. _
�, .�IflME Ot4'NER-BU;LDER DECLARATIOV � �� Name � , - �
� ;: Address t s ��{�`
� 1 hereby affam that I am ezempt from t}iz Contractor's � _ .
License Caw for the foltowing reasan(Secti�n 7035.5, Busi� City Tel.No. :t �� � j 6,,^ .
' and Yrofessloi�s Code):
1 �.c . . .. `,'r .
I,as owner of the pcoperty,am exdusivety contracting �`e
"� with licensed contractors ¢o eonsttt}ct the project � ,
(Sect'sun 7044,Business and Profession�Co�3e). � �,��.'Q� i �'�.`i
� CONS�1'RUC'PION LF:NUINf AGENCY � ,,, , - -
i here6y affirm ihat there is a construction lending agency - � _ �
for the performance of tiie work for which this permit is - � - . .
issned(Sec.3097,Civ.C.). � � � . .
a I,endec's Name '
e
Lender'x Address__,_�___ . � � . � -
$ I certify that I h�ve read this applimtion and.state that the - �� �
nbove information i.s eorrect.I agree to.comply with all Cnunty Sgg 2EVERSE FOR EXPLANATORY LANGiJAGF, - �
ordinances and Stnte lawa regulating Pluin�ing, and hereby � - � . - .,
i
author'ae representatives uf ttiis County to enter upon the � .
. auove �a��tioned pr p�[ for' sl�ection purposes. � � �
� ��� � � ��� � �
� Signahae of Permittee ate - - �- - � .
� �z ' � � c c� �'�s c�_�c�. � �,
,Anv � � r- cDi��C `.� n i� O Z
_ : „ � . _ � _ �� ... o .
, n,i � � m ;� p m -o = � �. .
z =o -o
. � D77 ' n � 'G7 m 2Iz v .tn �
—� r I r
� . � �.� �I -rii71, .. � I Ip
'.._,s p�i �I -x1!n' s��W I A
� C;D W '�i�
D ., I-n �, � ,. z O
i � � . ' . _ , r �°'� 'I o vi I� �� � A ,
. .. � . . . y. ., .._.. ., ��— . ,.. � �.
� F!l _ ,
� i
' I > O ; . . , � �
I D
� �
, ".: rn
z
. � '
� z
� W �
�I � . � . m
� � � � � - _ °
� �
� .
1 � . z
�
� �
� ! � �
m
I
I z_
,... , . ��� . . ' I . � ' . . . , -� Ci, .
i � € Q
j � � � f �7 �
3 �
4 � � u:
� � ; � � �
, , a
i ; i , � �
I
' ' � � , � ` � �
�
I .� t . � . � . . I ;. :. . i .. d ,. �
� j
f � i 1 , i'.
�, � ! 1 j I .
I � � i � � '� �
C ' I f' ! �
� � ' I �
� , _ �
� � � s I ; �
� E � � i ��• _ �
� � ., � i I � I
i , . .
; i
" I � � i� � a ; ,, � , I i � �
, , � :. .; �
,
.
� , �..
�� � r e �, E � ��� , �, „ , r , �� � � I � �� � ,
� � � �. ��-°w o � � fi:� � :n�^ ��-C-.���? �' ��.�N�C'�� .
C� � �i i ��, :�,zS �o n'� � cc � ro°-#� �.�'�s o � .� �'a.
� b.Y'� a..� '�ro o �' � ;�N r ,�� � o �.� � m ,
.. � � � � �,.b � •p � � � v� �s � a U � � � �.y. � �_�
m < «.Qo �.�w. �,
` q,e, h i�-• �, c,-� �.,-e �' _�
.. ' . - �- ..7il ,,� dC `^•cc} ;S O �� :�'.F� �".w^.� .-Pn' �'�'a �"�'� r� � c' q�.s: �,� � �'^C .�
� -.���• � �.. S.,� r� � �1,ro`-O� 'b a� ti p � `..� ��
- . . . . �., � `.�.. �-a� 5 �En� ��'�'-O.c� �.�n w����� -Y � �',_„-�-t .'P,Y7.
� O o �-,��y:a.,� cs � °'a... `�+�,o M �°'"'q q �,c„� � ;�
. "y ��' ro `� ��. t •�n co q_"" . 8� O
. �"��''' �, `°,s � Ga�"`''4'a � :a�,�°������ �a q���O aPo�.� iv��. � � .
' ��a o � �,�.�a n� o..�. t°°°+
� � �" z ootis �oa � � �•`= � °���
��i, � � — �� sro �"�^rs `�'� •,�„e�' �.n �� � � a � �
� � � . . . _ . c: �s3; ts, n "° ...
�. r, o ��.a�os �otl, ,�, z �""'ay^ � Q �� � �
.`�. ��`. o�� ��cc
, �.� a� � °��c ,"„„ .� a.ti.°nh�a� o n�. .� �.
- , . . . � . � �x sa'. a� A �m`�- � �.��w p n�� � - �i °' w'� !'1
_:,. .. .. w ,..
. .. . � ,; � A � 'D"C5 �� e� �,. �.�U`ma �; d � c`^o `�� � A�...,.,�.. �"
, , � � .:o ....:'�'� ��c �'�. �-C.o ».`"�, ,a.T'n �`� � � o ;8`
,. •�s�-"��p o h o � �.'�a b`0��v -. e• `c � �
, `o � � .a � ro w � � c�`o �..�^�,�� y'� o �` " `o w �
� o x� �a ., �- M � o �. ��
. " am � � �s �r� c� � � ��_. 400 �
,,��ro,` c ° �Ly�, p c � p� w� o '.�� v� �
., p O' r0 R N.-J s tD . .i", <o��` S k O'� q-yy.'�C"� p O p' ..
^, .� ae � � �� � � �,��.,� T� o � �?r .
. � . ro��,p A 5� n p ^f � c w:`C ��+n io vJ�n _``' `b`e:"o
� •