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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 nai Per Da�e ��" � � -. - � �------ - - � - - -' . _ C G� � 2 Gl � O Z . 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