HomeMy WebLinkAbout1838A WORKERS•�oMPENSAT�oNOE«ARAT�oN APPLICATION FOR PLUMBING PERMIT �� �
I hereby affirm ihot I hove a cerlificale of consenl to 6elf �bp��q �
. insure,or a certiiicote of�Warkers'Compensation Insura�ce, CE 817(REV.IOi81� - - � � �
o�e•ceriified topy thereof(Sec.380c0,yL^ob.-C.�) A _, COUNTY OF LOS ANGELES pBUILDING AND SAFETY
P❑olicyNo.S�ComponysJ'l!✓�•'�JV� ZS Z O _;��.;. - `
Cerfiiied�opy is hereby furnished.
O � , FOR APPLICANT TO Fltl IN(FRINT OR TYPE) 6UIlDING yo
Cerlified copy is filed with ihe tounly building inspec- AODRESS ��/a�
tion de prlment. , NUMBFR fil(TURE OR REM
FEE � ��,4LITY
pole �+ o`� APPIi4an1 ` • � n . 3 wnreRttos�T . $ Ob NEAREST .. . � � -
CERTIFICATE OF ExEMPTION FROM WORKERS' 2 BATH TUB z Q� CRO55 57. - � �
COMPENSATION INSURANCE OWNER � � .
(Thls��ctlon n�ad no1 b�compl�Md if th�work tnvoh�d 6y SHOWER
IM p�rmil b!or on�hundr�d dollon(5100)or la».) tqva70Rr �„ (�j nDDttE55� � - -
� I certify that in�he performance of�he work for which this
' permi�is iss�ed,I shall no1 employ ony pe��on fn ony manner S�NK CITY .N08� �
so as 10 batome subjec�to Ihe Wakers'Compenwtion Laws. D�SHWASHER pA � -
Q CONTRAROR ',S
Dale Applicont CLOTHES WASHER ADDRE55 L p �
�"'CE TO APPIICANT: If, ofter moking�his Cerlificale of � D �
� �,plion, you should becoma s�6jec1 to the Woikers' SWIMMINGPOOLRECEPTOR
� (,�fipensofion provisions o(the Labor Code,you must forih- CITY TEL.NO��-B4(„+
LAWN SVRINKLER SYSTEM u r
with mmply wilh such provisions w this permil sholl be ��N�,�.y43 7�i C1A55 l�� � �
deemed revaked. ' ' WATER HEATER
. LICENSED CONTRACTORS DECIARATION DiSiRiCi NO. SSED BY
I hae6y affi.m tFwt I am litenud under provisions oi CFwp�er 9 GAS SYSTEM OUTlFTS QO O
(commencinq wilh Setlion 700D)of Divisio�3 of the Business ouTlET50VER
and Profess�ons Code,and my license is in fuil face and effecf. 5 PER SVSTEM FINAL VALIDATION
L9 DATE � � 7 ��
License Nomber����l Lic.Closs� '"}�L3`� O •
��p ���� � . FINAL U.:
Controdor�t.K�UisLAm1�.QDaie �1/ � BY O
❑ I om exempt vnder Sec. ,, U,
_ B.BP.C.for rhis reoson � � W
Plan check fee � N',-
Do�e: p�UMBING VERMIT ISSUING FEE S
Z'
Signalure .
� TOTAI FEE � SO
. � � � � Plan check aPPlicant �
SINGLE FAMILY
HOME OWNER-BUIIDER DECLARATION Name � � � -�� - .'-'_j 8 3 8 A -
' �jby offirm ihai I om exempt from the ContraUor's ticense p,�dre::
� Jfor Ihe following reoson(SeUion 7031.5,Business and � �� »� � � � �,
Professlons CodeJ: Ci�y - �el.No. � . �
❑ I,os owner of the property,will do the work and rhe � e •9/l.J� .
sh�cture is not intended or offered for sale(Sec�ion
7044,Business ond Professions Code�. - � M1• ��'�,5�_
U
CONSTRUCTION IENDING AGENCY . . . _ . -- � � - � � �- - D S.(�9=H�J
I hereby nflirm ihal there is a constr�Uion lending aqency for
�ihe performance of the work for whith Ihis permil is issued ,
(Sec.3097,Civ.C.). ,
lender's Name � ' �
Lender's Add�ess
I certify thal I have�ead ihis applicolion and slate thot the ,
above iniormation is mrrect.I ogree to mmply w�ih ail Counfy � '
ordinances and Stoie laws regolating Plumbing,ond heraby ,
auiho�ize repre�emaiives of this Counry�o enter upon the � . � .
o e mentioned property or inspeclfo�� �
� SEE REVERSE FOR EXPIANATORY LANGUAGE
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