HomeMy WebLinkAbout1780A (10) 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 �
b = � � O 7
. . �Z 7 � � { � � � � A
.� s �,
m� � � � z a � � � � �
- DN p G� A s w �
. N� 7• � m . Z O D
� 0 � m p . � � �
� � p �
c ...
'� ,. ^,
1'
� __ " �i O
. � �
0 m
Z �
"�O � � ' (,(� .
m/`�S �•�
^ O N
� m
7�? �
N ' O
z � '°
N
0 �� �
.-1 i ^
m :;�� , 4,
N �L% �
�� : C
r �
' �I; , m
�i;� �� •
.. - z
_ �,
� �
, �
. �
0
_ A
� ,
. z
0
. �
, m
�
1 - . N.u�n3�.� io c� T
. �y n ti'�^ �p p (J � 'D In m m .
.J O 3 � � F O H� �7 w � ".� ,�.. 0 Q �' n CJ lT
� 3''� n fl a O �p �"'D N u�
� (p 9 �, ��p � �,O �V C ❑N O Q'� O V O ' W p �n N � O
O p Rp 3 �c`� ° 4�;c^ oa,� �..v�o�c oao� ov � f -" ' O
� �' , n X ' d�� o3NN !`oao., � �oo�N�< � -�co3' Z .
• m oq� � m � �.�. o . `'�rn ' o %: _'n.� 3O S *+�
o3 A ..o,•=•a a�. � � • —caT-`3 -� 0 � � N • ;v
.9 3 ., u �� � ' o ' �mvv � ° o u � woNo° G,
�o f o 3 yN � . x �-c � c � o ' . �
N � < `° aQ'o ° o � o °° nw '^ oa� �o � H °3 . o
• � N. � � f o n.q � n.0.� c�ro x w�� z�,� °a� K A
. o '� �=,To o H o' D o.,D � �� " �Tc'o ° "' � ,� 3 v
� , n �-o � m�Tv o � ° ° v v° �� °�
M g • n
�oQ.o �N �av v 'vD � 3 ° � � � _
� y � `" n O K O O.� O '+�G S h' '` O " N � Q O A
v m�c oS� o N � £ q3. � om � xo N 3 ^_. � 3 . D
. . ' . . ,N � (J p fD _. ^W "' K .
. , � U.� �9'U j � p O-C 3•C ���� O� Pi c Q O H n Q .
ovQ,� < a � �° o �� o3N3 ° N ' c�^ '�` Z
, . . N O n W f. � N.7- -••n 7 > � ' n • O C1
. � 3 n n ° � �r� ° � ~ ° �c^ � o � 0.c ? �
�
°�ov Q� �y°.A • £ ?�- '�-.04 � a°o f w�
N O 'O CJ v'�ry O O .�
, vo=.�� o ��' o . ir � o � �o , n '. "- • °
. . o n. � o � 2a o _ ' u, ,.
' �? ��+ � o ;��?o _.`N°, �� `? � ss
� � n 'o a a-. � M
2 7 O O �-K �
a�+
. l�—�
�—