HomeMy WebLinkAbout1780A WORKERS'COMPENSATION DECLARATION � APPLICATION FOR PLUMBING PERMIT y I I hereby oFfirm that I have a cer�iiicaie of mnsent to seli � 76a667n ' � � insure,or a ce�rifimte oi Workers'Compensation Insorance, fE 617(REV.10i81) . . .. _ . . .. . . � � L� or a rer�i�copy�h�(,Sqcf3BQ0,`ab. .� COUNTY OF l05 ANGELES BUILDING AND SAFETY cv�.i.�,'CJ.X��'` � Qq No. 1�� Compony ., - Certified copy is hereby furnished. � � FOR APPLICANT TO FILL W�PRINT OR TYPE) BUILOING 1`Z 1� 1� �� Certified topy is iiled wiih ihe tounly building inspec- ADDRESS l J 1 v fi n deporlm t � � NUMBER FIXTURE OR ITEM (� FEE Q �J�i�j � f LOG4LITY `������ Date I Z� �APPIicaM ��� WATERCtOSET NEARE57 /� /��,n /y^' CERTIfICATE OP EXEMPTION FROM WORNERS' BATHTUB CROSS 5T. l..�v,• '�.� C�'II��- - � � COMPENSATION INSURANCE ' OWNER r'e� -Q- � � (This��etton nNd no1 b�cempl�eod II fb�work invo v�d 6y • SNOwER . MAII /a Q� ` � : fh�p�rmH b for ons hundrod dollan(5100)or I��f.) , IAVATORY � A�DRE55 "G L / . I certify Ihot in the perFormonce ot Ihe work for which ihis ' _ permil is issued,I sholl nol employ ony person in ony manner � SINK CITY ��/�v;��- TEt.NO. _ � so as to become subject to the Workers'Compensmion Laws. � �. � . DISHWASHER . CONTRACTOR �(�'/ y ^ �L/� Date Apptimnt � CLOTHES WASHER AODRESS ��^'+/�"'6 r � �G/�[� � � NOTICE TO APPUCANT: If, ohar moking this Ce�tifimte of Eaemption, you should become su6jed �o �he Workeri SWIMMINGPOOLRE�EPfOR ��TY � TE�.N .630�6� Compansa�ion provisions of the Lobor Code,you musl Forth- � (qWN SPRINKIER SYSTEM v � �� � with tomply with such p�ovisians or Ihis permit sholl be - ? STATE IIC. �"' /J � dBBmBd f9voked, � . - WATER HEATER ���N�No.L/3�3 J�3 CL455�/� ` _ . LICENSED CONTRACTORS DECIARATION DiSTRiCT t�0. PROCESSED BY I hereby offirm fhot I om licensed under provislons of CFwpter 9 ' - �-+`SYSTEM� pUTtETS •7 (commenting with Section 7000)oi Division 3 oi the Business oui�[T50vER �� ond Profeuions Code,and my license is in full force and eifect. 5 PER SYS7EM FINAL VA�I TION 3l .�� �� DATE r. �{��f, O Licanse Number lic.Closs ^ ��/ �/� � / ��l�� FINAL - U. Conkactd�'tyt «'�'�`c �' � �� Bv � � O I om exempt under Sec. H U: B.BP.C.for thia reoson W Plan check fee , N Do�e: pLUM81NG PERMIT 15SU�NG FEE E Z� - 51 nolure ' �' 9 TOTAL FEE �1 7 8 0 A � � � � . Plon check applicanl �� � � � �5 SINGLE FAh�ILY HOME OWNER-BUIIDER DECIARATION Nome � I • • � �i S O II here6y aHirm Ihot I om ezempt from the Con�mctor's License Address ' � r. _ � � Law for the iollowing reason(Section 7031.5, 8usiness and - � ' � ����+ Professions CodeJ: City Tel.No. O�,O H—H�I ❑ 1,os owner of ihe prope.ly,w�ll do�he work�and Ihe structura�is not iNended o�offered fo�sale (Sec�ion , , 7044,Business ond Professlons Cade). � � - ��� � � CONSTRUCT�ON LENDING AGENCY . . �. . , . I hereby nffirm thot there is a conslruttion lending agenty for . � fhe performance of�he work ior which ih�s pe�mit is issued , . . . (Set.3097,Civ.C.�. . . . Lender's Name . � . . . . . . . . . . . . . . . . Lender's Address � � ' I certify Ihol I hove read Ihis apptico�ion ond stale Iho1 Ihe � . above information is mrreU.I agree to tomply with oll County ' � � � ordinonces and Srate laws regulo��ng Plumbing,and hereby � aulhorize represeniaiives ol rhis County to en�er upon ihe �� � obove enfoned prope�ty for inspection purposes. � - � �� ✓� SEE REVERSE FOR EXPIANATORV LANGUAGE � SignaNre of Permine Date � �Z 7 � D c O D D � 7 N� y C N ; f/� N C O . m y .� -� �P � < � = A D� n N z -�a Z � m .tn- Y � ; �� O � � _" � C � v . , . � 0 7 X = S � w r O � �. c ... � ' � D O � -Di Z � � I _ � .. . D � A • � � N � . \'l Z ' � N � �p ! m � D A ' _ .. N '' 0 Z � O z m . .o � ,'i n f O ' 7L v '( 1 !%N ♦ � if Z •!�•, ,� " � ' C .\J Z • N � m n � 0 . � �, , 7 , O � � m N I -- - _ . . '_ • - � • . . � � � �, fl f j� A � O w'A m �] W� � n � � � o� m c�D �p . c � � :0 3 �c� ° a�C�C�N ❑� ~ in �-� o o ~ w� � � N o � � ' �n X ' -•tr,� O S C n O� _ O P IJ 0� n S O M N � a' m a�. 3 R 3 ' � �c u o�c o a o° ° �' o •o fl o. 3 � a� ' ^'"� ms ° o^ o �o��-o o�.� � ° -o �e o ,,a r-c.„• o o:.��o o r-`°v.< ° a � O 3 � • N . ? 'oFN 'o F � o � .. �� ao�.3 �0'.. 3' ° ° s 2 . 0 �o � _ 3a'" -� � a�=� � vN � � 2 ' N�-o ' ;o . � � O . N. A C Q��O u o 7 O O ^o n r7 i�'.: r�cG O� ^ o �.— � C"i^ " . � :cn oaF � a`o � 'a> >- <' � 3Hooa' mN � oo C . � , n ' j.�'o �-uT ��a� ='b � � fa � a3 0 �o �m° s o 0 0-v � ° � � `''n N �-�. c o i � m � �� �c �v r �v ° � � �'4 0� ° ',^'a- ,a � A � n.'� S�-o�c�. om 3� ��= �.v � o ."" 3 � o �u F ? o' N m'c o 3`� �W� 0 3 °. � � � � � , mo,o ,�v3 � � naf � � < oN �o �oa' '. nao � ' «o -"' < af �oa n`o-o'o'� o� �� � � ' 3 . D o �. o � � F � H ° ' �o 0 3 � 3 'o 0 0 0 o ti�- , . c� 3 �?� o� yo:� -..., � o '" 3 � H � �-n � n ' � � �'�-��'„- a°.��' � � � o a� � o� ° a� � o. o - � °� o s�'�.�-�_ � o o �� � . �.� a� � o � . x- � o ,��c �� �aM� '� o� . . n � r� � .. 2v � °�� o o F w� 2 `a � � � 'o ° �� • ° ,� ° N . • ° . , a�° OS-< ^ 'a a=� » '^ ��`? c', :r`s�, �,