HomeMy WebLinkAbout1784A WORKERs�aMPENSAT�oNOE«ARAT�oN � - APPLICATION FOR PLUMBING PERMIT {� �
I heraby affi�m tha�I hove a ce�nf�co�e of consent to self �yq��A ��
insure,or a certificote of Workeri Compensation Insvrance, CE 817(REV.10/81) .. . . . � ,
or a cen�fled cop��t ISec,38qo,,l�C.)�^�C��� COUNTY OF LOS ANGELES BUILDING AND SAFETY
-7 c,�T�0"�7 �=
P❑ol'�cy Nd��Compony �7`'' � ' .
Certified mpy is hereby furnished.
� FOR APPLICANT TO FlLL IN(PRINT OR TYPE) BU�IDING T � )�n�^�^ ,
Cerlified copy is filed with�he munly building Inspeo- A�DRESS J � Ltii'�/
lian deocrlme - NUMBER FIXTURE OR ITEM � FEE ��y�ITY � �����
1 "1
Da�e��Appl i5on��� �N/+TER ClOSET NEAREST �, ,) t
CERTIFICATE OF EXEMPTION�FROM WORKERS' BATH Tue �ROSS ST. ��11 �'(�C�rnG�
COMPENSATIpN INSURANCE . OWNER p�C� �
(ih�t��Mion nNd mt b�compl�Md if ih�worlc�nvolved by sHow�R .
th�p�rmi�(�For on�hundred dellors(5100)or I�sa.) t.4vniORY ��l / `l L/ L 1
ADORE55
I certify tho�in rhe pe.formance of the work for which ihis �
pe�mil is issued,1 sholl no1 emplpy any person in ony monnar SINK CITY -.1���� TEL NO. E,�' LC,�
-- so as lo become su6jeU lo Ihe Workers'Compenw�ion Laws. "-
. DISHWASHEft COMRACTOR���Gt� �,��1'
Date � � APPlitont � CLOTHESWASHER � ADDRE55 Li�Cs � �
NOTICE TO APPLICANT: If, of�er mokinq rh�s Cart�f�m�e of SWIMMINGPOOIRECEP70R '
� Exemp�ion, you should�become subject to ihe Workers' . �
Compenso�ion provisions of�he lobor Code,you most forth- CITV ��� TEI.NO. �I ,
LAWN SORINKIER SYSTEM
with tomply with such provisions-or this permit sFall be STaTE i tiC.
deemad revoked. � - � WATER HFATER . UCENSE NO. - 7I CLA55��
IICENSED CONTRACTORS DECLARATION DiSTRiCT NO. �ROCESSED BY
, 1 hereby affirm 1ha1 I am licensed under povisions of Chopter 9 � GAS SYSTEM OUriEtS � � Q
O•�
(commencing wilh Section 7000)of Diviaion 3 oi Ihe Business OUTtET50VER •
ond Profetsions Code,and my license is in(ull farce and effect. 5 PER SYSTEM FINAL VA�� TION
�,J'J�-r�1-� C �, DATE �� a
License Num6e��/�✓"�� Lic.Closs�(
d ���Y�Lfi%fl'��� .!�'� `� ' BY AL O..
Contract �.
❑ I am e:empt onder Sec. r 1 7 8 4 A �:
B.BP.C.for this reason W
Plan check fee t # • • • • •S a
Oate: p�UMBING PERMIT ISSUING FEE f I ' ° � �S O Z
- Signature - . ^
� TOTAL FEE • • • � 6 j O= ..
. .. . . � Plan check appliconl � � O a_8'�
SINGLE FAMILY
HOME OWNER�BUILDER DECLARATION Name� � �
I hereby affirm tho�I am ezempl from ihe Controclor's ticense qddress � -
law ior the following reason(Section:0�1.5,6usiness and � � - �
Proiessions Codej: City Tel.No.
❑ I,as owner of Ihe property,will do the work ond the
strucwre is not Intended or of(ered fof sale(Section ,
7044,Business and Professions Code). � �� � � � � � � - - � �
CONSTRUCTION LENDING AGENCY .. _ . . � . . �
I hereby nHirm thar ihere is a constrottion lending agenty for
the pe�fo�mance of ihe work for which this pe�mit is issued , ,
(Sec 3097,Gv.C.�.' . .�
Lendei s Name
Lender's Address � � - � - �
I certify ihoi I have read�his oppiication and sto�e tho�the �
above informo�ion is correct.I agree ta comply with all Co�nty � � .
ordinances o�d S�a�e lows re9ula��ng Plombing,and hereby "
authorize representatrves of this County to enler upon�he � � �
obave-ment�oned property for inspec+ion purposes. SEE REVERSE POR EXPIANATORY tANGUAGE
,� � . � .
ign��ure of Perminee Date ' �� � � �
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