HomeMy WebLinkAbout0850A ,� WORKERS'COMPENSATION DECIARATION y �^�'~ ~�"'—Hfi-�.�GATION FOR PLUMBING PERMIT� �� � ' {� I
I rereby oflirm that I have a certifimre of consenl to self �yAyy�A � , .� � - • � �
i.,'sure,or a tertitimte of Workers'Compensofion Insurance, CE BV(REV.10/91� .-. �. . .. . � - .- ' U
�or a cerlified topy Ih ieof(Sec 380 Lob.C)
'' :,'. ,. ' .,..: ....
� � Da�D - - COUNTY OF LOS ANGELES BUILDtNC�AND SAFETY
POolity Company ; . . - ,�- . �
Cenified copy is hereby lum�shed,
� - FOR AP7LIUNT TO FILL IN(PRINT OR TYGE� BUI�DING ' ' ' � n
Certi(ied cvpy is filed wi�h the counry building inspec- ADDRE55 /� C..�Q
tion depa Imenl. . � NUMBER� - FI%tUREOR I7EM � FEE .�/
C1����",, LOC.4lITY � 'am0. , ' pv� I
Date__L��!j.��•t AOP�iSOM I � . _.. ._ '_ WATFRCLOSET.. . .. .. . ...... . ._. . QO ry�AREST . .
� RTIFICATE OF EXEMPTION fROM WORKERS' BA7H TUe `. ��, CRO55 ST. � .
� � . COMPENSATION�NSURANCE��- - SHOWER �W�R �� � -
(Thb-�Mion nNd nol b�comp6bd if Ihs�+ork involwd by �� •
nnan
1bs permit If!or on�htlndr�d dellors(SI00)or ins.) IAVATORY AODRF55 -
I cer�ify�hol in�he periormance of�he wak for which Ihis ' �;
permif is issued,I sholl no�employ any person in any manner �� �"�� SINK� � ��� �� � � �� -��-�-� �- �� ��� ��� O� [I �.- �,��
_ so as ro become subiect fo rhe Warkers'Compensotion Laws. DiS�iwnS�+ER �
- � G-- CONTRACiOR /S �/
�ob Applicant� - CLOTHESWASHER 0 A�E� � �_) •�// �
NOTICE TO APPLICANT: H, afie� making this Ce��ificote of ���� t '
EKemp�ion, you should 6etome subjec� to fhe Workers' SWIMMING POOL RECEttOR
CITY
Compensofion prov�sions of the lobo*Code,yoo must forth• � - - �qWN SORINKIER SYSTEM � � �
with comply with such provisions or this pwrmil sho�l be SiA7E p IIC. A +J!_ '
deemed ravoked. ,, , . . -�- -�-- WATER HEATER ---- � � - - � - � .O� LI�ENSE NO. 7 CLASSG�'9!P
� LICENSED CONTRACTORS DECLARATION � �iSiaiCr nip. ESSED ev .
I hpeby offirm ihpl l am licensed under provisions of Chop�er 9 GAS SYSTEM OUTLETS O, � -
(commencing wirh Sec�ion 7G00)of Division 3 of Ihe Business OUTIETSOVER ,
and Professions CoJe,ond my license is in full forta ond eHect. . 5 PER SVSTEM FINAL ?� VALIDATION �
_ �
license N err��Lic Closs ��3� ��� (� DATE �' ._ . . O:
, . . .. . . .. . . . . . . .
� �/ v FINAL . . . . V ,
Coniractor Da�e �/ �a BY
._� -__ .. __ ... .__. ..._.. . _ . .... . __._ . Q+,
. ❑ I om e�empf under Sec: � - �:
. ...... .. ......._ ._ ... _....... .. . . . . .. .
B.BP.C.for Ihis reason � laVj
Plan chetk fee a
Dafe: p�UMBING PERMIT ISSUING FEE E 6 O ^
Sig�olure . . . . . ..
TO7AL FEE :Q S S.O A
. � ... P7an�check appliconi_ ._ . .. ....__._.. . .. ..... ... . . �• • • • ��j ��
SINGLE FAMILY
HOME OWNER-BWLDER DECIARATION .. Name . � I • 1 3 6.5 0
I hereby oHirm thot I om exempt from the Controctor'S ticense Address � �� � / (f � - �� '� � • 1 3 Q 5 9 Ei
Law for 1he following reoson(Sedion 7031.5, Busineu and . _.. ,_ , . . . ...
Professions Code}: � City �A Tel.No.3 ��� 8�8 7 �
❑ I,os owner of Ihe property,will da the work and the � " � . '' � � � �
structure 's no1 intended or offerad for wle($ection , �
7044.Business and Professions Code). ...... .. .....—._ .._.._ __... -. � . .. ._.._ ._._._... __., . .-.- _-._.. _. . . . . .. . ;
� �""CONSTRUCTION LENDING AGENCY � �
. . . . . . ... .. . . .
I hereby nffirm that fhare is a conslruUion lending agency for � �-- � � � - - - � � - - � � -
the perPormance of the wor4 for which this pe.mit is issued �
(Set.3097,Civ.C.). ....-_ __ _.. . .
. . ._ . . . . _. . . _ .. _. _ ... ..... _.. . .. . .. .. . .
lender's Name �
Lender's Address . .. . . � . . .. . . -.. - .. . .. .
I cerrify�hot 1 have read�hrs opplico�ion and sioie tho��he � � � - ,� " � � -
abave informvtion is correcr.I ogree io comply with oll Counfy ---�- � � � -� � �- � - - � � � � � �� - -
o�dinonces ond Store lows regulating Plumbfng,ond hereby �,
authorire repreiento�ives of this County to enler upon�he . . . . . - . . . . . .. . . . . _._ .. � �
obO e-menffo�e property for inspecfion pu�poses. �
1 ( p. G qn SEE REVERSE FOR EXPLANATORY LANGUAGE
� j O '�d �O/
Signalure o Perminee Dote -� �� � � � � - - � -��� - -� - � - � � �
l i
_ _ __ - --- ,. � = D D C
- - ---�-'. '_. �z z � N c Q � � � �
. .. ._. �c ;� -�G r�i � > Z �" = v' D
_ - . . . , D� ' ' O � � A � � C � A
� . �r i� A � '� `�' � �
�
'i • Q � A
� �
�1
. . ]
. �..
' ' � �
� . • � N � �
Z ' " _ O'. . tOy .� m
N , V
. � = a Z
° � � �
Z . . . - .
� . . - N
� . _ �
' '"" . . . �. . K �
' ' . ' . '" �. � '
I� � . � N�Q
' (' '/
� � � �
� r :.l p a
�
, ' • ; / ' '' _
�
- �
, . � a^ VoNmo3 co � m � �.'
'' � 7 O 3 3 � �.� �m O ��W l 7 � � .�.O'"ti� C.7 H m � \
, 4 �- •'•� lC'0a0 ^ O ~ h4C n in7Oj � 'MO�HN � '<'i .
O. `° �• 'X a�.3 n„3 a� Tc�l^„°"` °m V$�.To �� Q a o.' O
:.. �^ ' fD p _' 0 O� �w m W O � g t,��p �" r N'�'� 3 � ° 3' Z '_"'��
�� ° v � A -°, ooM " � � ° °.T`� � 8 � " OT0 �,70
, s c � { « �� Em �.°.� avn °Ou � 3��n3N m ^ m
0 3 u � x n
N . ' a < �-o�.cL�° mo � o ° $ � ow: aa' a > ? oo r
1 . p �0 .o m �� a'm � a� W o �� � � x c nv � o f �o � ._
. m :.u+ � s s o ?N w :�v ° ° n c'n N S�' � x , A
� a
� � Tozro°.�� ° o0 oa � 3 °.�o m � o=-'o g "� d .
' ° �o �'o M 'o "v D� v � v_- .n
w3 ;^nN.��' O � 3W ' O� 3.-� i030 ... . .�
" � _ �.� �m u �� ° N � £ � 3. � m � 'D�°N^� ^_ j �'.-� '
_ ' , � . . �'� O � �0'O � 7 ��� o` O -�'�^'-�m�+.M�,S -�_ �
� , < � � O ?C q p � O V� W O H 7��.�
' - �.� g.'�° � af ,m4, ° o �°� 3M 3oo�.a � � �a '.Z
o Ao N t_u � ,� a -. n
o < 0 3-3 �-m o ` „= ' a o �e N � a c o o -
. o' 3 o m o �,m ia � � a an � o � �a°> ? . ,.
� �' . . . y'O?m C w OO V,� fl � C� m� ��= O �O C,f t�.a^
> > � $�
•_, . S] 7 m N O O 0 a.,� � N N S T 0 � .J i�y�O •-
, • a i° � � �° p. q=:� � �-m
_ _ 's o o �..�
� . 4 d �