Loading...
HomeMy WebLinkAbout1784A (10) 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 ' �� � � � A x 1 G� � � O Gi � C � N � 2 U� Y ��-' �1 1- %�gm �% Y Z Z G � p � y o � � � �- ,n � ? � O � � . ' ., m.'�'�p � yc 2 Z � u� .. : �S O G � . � '� ` �� � M � �. �, '�' D , D . r ,. � m . . . s • . ' ' o � . , _., : ' " - Z . . .. - . � `ro . , � m _ .- , p O 2 � . " j0 cno • � u� fn G� Z � � p ' r: n . Z �f' ' r•,; � . 0 �,. ' . N i. . . . .+ir:. • � . � � A N . � � • m N ;,� . , , po m �c ^� �'' � N �� m C' � 7 N �' ' � O� � ,�..?+ N'U Q �` � `[' W O �n . ' , � �0�@ °-Q3V`oo� ° °�=; ° �<�, .O � ' ' .� O.3 .�..O Q v n % O N O p� 9.O� ?Oy �� a' a . L �7 (p r-..1 G .[. O �o�n m .e. � o .Z � � � Q'n j�' N� o � �r y��.N � � ? ^y . . '� � 6� 4 . .Q'A-. < p?�•(0 �G, O O� 7 'p � p i� ...p � .� N Sp C . '\ p Qo �3 5. �o a.3 C.u� m co '" o=-``' n.�' N o ?,n o u. ° � \ Q O 'O ' (9 O.C 3 O m N � � N � '� .0'O ,�,.� � � G � � O 0 .Q . � `� � C� a o-. a-� o'....,o�o � > > a�% SN. �o ° � � N '� ,�, 9 � � ` v i �e °� _� o � c n- - ". c�f � � ' �-°. p •-o �J £ '" m �3a.N � °, ,�,�.'�o � � �c �'O�a.� � � • G o=oa.Q.o�� � y � - x wn� � o . `'��' 3 C� �: 7 < T a.o a c � O-O-P �� � o 0 0 „ n-.Y�9 �`� .. w O- a fl � N o -„o c� ,o � 0 3 .n � 3'0 � � p .� � , o :.N o TToo ��oo �vY�'� = 'o "' M - ^_.� � �� T 'C> co � �. . � ' �n c� •T a � ° N n.,-v N �'•. 3 'c � �y .o ...o N 3 .t O � � _ n , v� m si� o N `�: " N o'�o.� Q �° � ^� Z e°"o� ° o n o-% �'c ° ° N 3 0 ,� ,, � ° o 0 o � .3 N 3 <, c, a o �. � p..� m� � �p�-��° ° �.n«? a > > o � o �'' -� on • . -' . o.ao G � 3 N ^ < N o °'.a.`-'. Na. 04 �,t. , . � N O ^O�3 3 O^ �,p� � 7 ��"O u'. Q �� N -S �L �'Q N Q . ' °� 3w � a°'.� o c o �a'� -.�� � - � ' .. - v?�� N �O� . r O"� O N.N � O u� O i7 - 7 `" . , ' ?j 7� �� � d Q , ' � . . . 6�0 O ?� n o„Q -