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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. 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