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HomeMy WebLinkAbout1373A WORKER$'COMPENSATIONDECLARATION � APPLICATION FOR PLUMBING PERMIT � - I hereby,aff�rm ihot I have a cer�ificore of consen�ro self �gp867A insure,or a cerlificots o(Workera'Compenso�ion Insuronce, CE 81T(REV.8/88) - � - - � �- - - � � � � - � �. � �- � �� ��� . or a cer�ifled topy�he�aoqf(Sec.3800,lnb.C.) ... . . . . - - . P�ol�cy�10.6'1�3949't6�pony�_�nnn� COUNTY OF LOS ANGELES � � DEPT..:OF PUBLI�.,WOAKS � Ceriified copy is here6y furnished. � [71 f-0R APiLICANT l0 Fllt IN(PRINT OR TVPE� g�����' S . 1XI Ceriified eopy is filed wi�h the county building inspec- '1'��R� , ?� tio�depo��me�t �, NUMBER FIXfUREORI7EM � FEE ����TM pote9�8�_ApPli4ont���l„�j{�' WATERQOSET NEAREST , • . CERTIFICATE OF E%EMPTION FROM WORKERS' � V BATH TUB 1 -� CRO55 ST. . � COMPENSATION INSURANCE � . S��R OWNER ' , . .(Thl��Mion nNd�rof b�complN�d if IM work Imolv�d by �i� . .. _ . th�p�rmN Is!or on�h�ndr�d dollan(5100)or I�ss.) IAVATO4Y qpp�� � ' •.I tertify thol in the performance of the work for which�his . - permit is issued,I shall nol employ any person in any manner SINK , � CITY �4�'1� � __ so as'�o become subject�o the Workers'Compenwlion laws. /� - � . UISHWASHER �p � CONTRACTOR \�C ❑ate ' �pplicanl � � CLOTHESWASHER� � . � �T�CE i0 AVPLICANT: I{, oftar makinq this Certifitate of ��� � d � � � . mption, yo� should become c�bject ro �he Workeri SWIMMINGPOOLRECEPTOR �Compensolion provis�ons of ihe Lobor Code,you must forth• (AWNSPRINKLERSvSTEM C�rv � e�`'�'� ' with tomply with su<h provisions or ihis permit choll be S7ATE �` Q C� ^ dECmCCJ 1CVOkE�. WAIER HEAiER ���N��. � �• - � UCENSED CONTRACTORS DKLARATION� D�STR�CT NO. PROCESSED BV I hereby oifirm�hai I am licensed undar povisions of Chapter 9 �SvSTEnn OUilEiS �IM!1 � (tommencirq wi�h$eUion 700D)of Division 3 of the Business OuiLET50VER _ . D "A �� � ond Professions Code,ond my lice�ae is in full force a�d effect. 5 PER SYSTEM FINAL VALIDATION � �313083 C3(n DAiE �. f��rg' � License Number lia Cioas �� FINAL �}' �/ O Contracror l�� �e��_ BY (�`"�°i"'�/ U d� �I�am eaempt under Sec. y . B.BP.C.for ihis reason plan check fee - t :"1 3 Z 3 A � �ate: � PLUMB7NG PERMIT ISSUING FEE S � i�• • • • •S Signalure . . - TOTAI FEE �'j0 1 • +8 E 5 0 - . . . - . . .� Plan chack applicont • , �R�.J(�� SINGLE FAMILY . l HOME OWNER�BUILDER DECLARATION Nome �g+'J(i�8 7-- -- 3reby oHirm thot 1 am exemot from the Contractor's license q�dross � � � - � � - �- low for the following reason(Section 7031.5,Busineas and Gro(essions�ode): City Tel.No. ❑ I,os owner of ihe prop�v�y,will do rhe work o�d rhe , stroct�re is not infe�ded o�offerad for sole(Setlion ��� - - - - � � - - - � �- 70�1,Busineas ond Professions Code�. � � � CONSiRUCTION LENDING AGENCY � � ' � ' � � � ' � I hereby offirm�hat there ia a cons�rucrion lending ogency for the performonte of Ibe work for which this permit is issued - � - - - � � - � � (Sec 3097,Civ.C.). _ ._. . _ Lender's Nome . � Lender's Addross - � I certify�ha�I have�aad this applimrion and slo�e Ihot�he � . . . ► . above informotion is carect.I agree to tomply wilh oll Co�My � ordinances and S�ofe laws regulofing Plom6inq,ond hpreby _ . , . ouihorize represemalives oi�his County to en�x upon�he obovrmenlioned property fo�inspeUlon purposes. . ,p (� SEE REVERSE FOR EXPLANATORY LANGUAGE Sbe�js��-�.`(1�ie+1vOD-� l-3`�� Signolure oPPermil�ee Date � , . - .. .. � ' C � �+r S � G1 ' . .. . z - n c o � r o N� j. - (n - N �. c ii m� < T ', . � c� � �._�..,_._ �,. -- � -r; v ; �.� I , � ., ; i ".- � ;'>;. _..:._� F �� _ - � T -- 'J � x. � � .a T� Gl �: w i. :V Q i r� � '1I... �, � b � (. . � �' ..JG7 � I:I• '�l� �' �'��n I� i: � � . . i... i • � : ��. i� V ^t ,y).1 -1:� �1 � N . . � . .. �• ' ' _.i� �:i' . t-� • ��,-� �� ' . 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