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HomeMy WebLinkAbout1375A (7) WORKERs'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT � I hereby,affirm thot I have a certificate of consent to self 78A687A � . insure,or a cerlificaie of WMke�s'Compenmtioa Insurance. CE B77(REV.-Bl86) .. . - � � ��-� .or a cerr�fied mpy thereof[Sec.3600,Lab.C.) . � � O� b���� Y��.��u� COUNTY OF LOS ANGELES DEPT. OF'PUBLIC.WORKS Poli Na. ompan -�� '15 "5 • - �. � Certified copy is hereby furnished. FOR APDLICANT TO FILL IN(PRINT OR TYPE� BUILDING � Certifled copy is filed wilh�he eo�nty building Inspeo- A��u ' liondeparlmanf. NUMBER FIXTUREORITFM Q FEE LOCAIIN. �\ �(V�,b ppte q-3—.�3�7 AppliSanl � WATERCL06ET � CA NEARESi , 'a, anrH Tue caoss sr. � . CERTIFICATE OF E%EMPTION PROM WORKERS � � . COMVENSATION INSURANCE ��R OWNER. ..� . _ . - . (Thb��ctlon nNd nW br cornplN�d tf Ih�vrork Innlr�d by - - . . . . . th�p�rmit I�(or on�hundr�d dollan(5100)or I�sf.) . � tpvniORv �� M'�'�� � ADDRE55 I certify rhai i��he pe�formance o(Ihe work for which this . - permil is issued,1 sholl not employ any penon in any monner S�NK OiV' � �'1� 5 . �— so as�o become suhject to the Workers'Compenwtion Laws. � pi5HWA5NER : . � COMRACTOR 1�e _ Do�e ' 4pplicont CLOTHES WnSHER p A��� 1 �1TICE TO A7FLICANT; If, oher mokiny this Certifita�e of SwIMM�NGPOOtRECEPTOR bmption, yoo tho�ld betome wbject �o tha Workers' " I �Gompensorion prov�s�ons o!rhe tobor Code,yOv'�ust forth- LAWNSPRINKLERSVSTeM C�TM � �p�� ��' � with comply wi�h socb prov�slons w th�s permN shall be STnTE ^� *� uc. deemed rovOked. �� WATER HEAiFR ��NSE NO. v� v CV�55 � � U�NSED CONTRACiORS DECLARATION � � DISTRICT NO. PROCESSEO BY I hereby affirm thpl I am licansed under provisions of CVwpter 9 GAS SVSTFM OUTLETS /� a � (commencing wi�h Sec�ion 700p1 of Division 7 af the Business pUTlEttpyER �� � 'O�e �' ood Prafessions Code,ond my Ilceroe Is in Full force and effxt. � 5 PER SvSTEM � a Q� � DA E� �- i J� VAUDATION � Licenae Number��3�C3� Lia Class� ¢ Q� ���-�(�----�� FINAI ,�/�� O conkaaw re �� . B� !/ry U ❑ W I am eaempt under Sea y B.BP.C.to.rhis reoson , ' ? ' Plan check fee � �1 3 7.5 A ���� PIUMBING PERMIi ISSUING FEE S � Signo�ore � . «• • • • •5 . . . . TOTAI FEE - I �+ •7�i 5� . Vlon check oppllcanf SINGLE FAMILY . � s • a�J�5 O� - �` HOME OWNER-BUILDER DECIARATION Name � � 5reby offirm that I am evempt from fhe Contractor't License q�ress � � �7'�u��7 . tew ior Ihe following reason(Section 7031.5,Busineas and Wofessions Code): Ciy Tel.No. � ❑ I,as owner of rhe property,will do fhe work ond the _ irrocrure ia nar in�e�ded or offered for wle(Secrion . . ► - - � - . 7044,Business ond Grofessiona Code). � CONSTRUCTION LEND�NG AGENCY - - -�- � � - - � - � I here6y oHirm thal the�e is a construtlion lending ogency for � - � the performonce of Ihe work for which thia permil is iswed � - - . � -- - (Sec.3097,Civ.C.). . lender's Nome � � Lendei s Address " � � . I certify rhat 1 have rood rhis applicmion and siate ihm the . . . - . . ► . . . � obove iniorma�ion is caroct.I ogree to tomply with all County . . ordinances ond Siate laws regub�ing Plumbing,and here6y _ __ _ . , _ outhorize representotives oi ihis County to en�er upon Ihe abave-menrioned propeity for inspedion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE � 9-3-�� Signoture o ermillee Dale ' � � . . . . . , . C ^ . S G� � n � Y c I � Y c U y D U z L'+� D - N � N C �) � . I _ - , ..... , "'-I _ .r. _ '< ^, ' : ! v G7 ;� I • �. I ''� n (~ - J ' 7 r D _ - f., .✓,...; ;,j- �i�+'' T? �' :", c� c r �, � r � � CJ� I < � �y x, � i f 1• C> � �� 6 . . • . . i j,, _ I T, ' �� � 2, 7 � � .... ( . . . . , �.a, � � r j j �� � n,�� 6� •r- _ . , , I 5.. �'��'1 h'r �.I`�I v �� z;. .� ., N . r�; ,� � , i �� , � • - ' r ' 6��• .j� :` •,=�� :• �" ^, ';' . � Z : _.. _ i .� � i _v ,!y_,� � - . . . ,- �� � : ; �. � ,� GI1: :..... ,1 1 m i. 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