HomeMy WebLinkAbout1294A (6) i
WORKERS'COMPENSAiION OECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm�hat I Irove o cer�ifiwte of consant to salf �y�yyq . '
inswe,ao�a cenifitate of Workers'Compenanfion Insow�ce, CE8�7IREV.10/81) � � � �
. o�o cernfied rnpy thereof Ser�.3800,loE.C.) . a
7S�S GOUNTY OF LOS ANGELES BUILDING AND SAFETY � i
Po�I'�cy No. ompany FArrncfiS � , .
Certified copy is herehy f�r�ished. �
OFOR AV%ICANT TO i1LL IN(PRINT OR TVPE) � BULLOING . .
Cm�ified mpy is}iled wilh the counly bu�lding inapeo- ADDRESS 1 i �1 i
fiolf depaAmenl. NUMBER ' flXTURE OR IiFM p FFE 1�1�
� y� A� r�1
oara AppliSaM�Q�l�3• �U117�1 AIC1 3 WAiERC105E7 �
NEAREST
IflCAtE OF EXEMPTION FROM WORKERS' � �Y� BATH lllB ' � Lli7 ���•
COMPENSATION INSURANC� � SHOWER � Q� �R , , j
(Thb��efion nwd not b�eompl�»d IPTh�work lnrolwd br a� _ ;
1he porm�t Is for ono hundrerd dollars{SI00)or loss.) uvATORY � qapp�u � � , rv i
�eenlfy rhat�n tha performanca of the wovk for which rh�s .
permit is iasued,1 ahall not employ any person in any manner- �� � C�Tv N iFl.NO.�"j'�1 �
so as�o bemma subjM�o the Wohers'Compensation lpws. D�SHWASMER + ti '
(J[� CONTRACTOR
� � ,
Dafe . eppliCOM QOiHFS WASHEk (�j� ^���)J .
NOTICE TO APPLICANT:1f, aher making�his Certl}imte of —r ;
�nption, you should becoma subjecl m the Worken' SW�MhuNGP00lRECEaIOR � � .
-,, .I�pensarion provisions of the Labor Code,you musf fvrth- ��TM ���� �' '
(AVM SPIdNKLfR SYS7EM . �
with comply with such prorisions�or tbis permit �hall be Sia�E lIG
deemed revoked. WAiFR HEATER �T���� �S '
U�7VSED CONTRACTORS�ECUIRATION � OISiRKi NO�a qtO�55ED er . '
I hereby affinn thaf I nm licemed vnder provisiona of Chapter 9 GAS 6vSiFM W7lEf5 � G (/v �
(commencing wilh Setfion 700D)of Oivision 3 of Ihs Hufineas pURE15pyEp . y ;
aMl Rhotes�iom Code,and my license ia in full force ar�effect. s�Q��+ fINAL V LIDATION Q i
LicenseNumbar�-I�1377N �ic.ClassS�r�SQ_ . DA�E ��D�{� V �.
FINAL � i
� � ,
ConhcUvr Da1e_�_ . BY u
� I om eaempl under Sec. �• d �
. V1 '
B.RP.C.fw ihis reason , , � :, 2
Plan check fee . t .: ;
Date: pLUMBING PERMIT ISSUING FEE S U � � `�' "t; �
S+g�awre - ��=1 ?_9,4 A �
TOTAI FEE - O O � �
. . �. .5 �
Plon check oppl�coni '
Honne owrieR-BUIIDER OECIARATIQN NOme � • 1 C 0.5 0 �
. . .. ,
6y ptfirm thol I om e:empf from Ihe ConfroCw's�icqnse �� , • • � 0 Q 5�� �
�for ihe followirg reason(Section 7031.5,Busiriass and ,14 • .
a
Pr6fes3ions Code): � City iel.No. • ' a 7,1 2=8 5 - j
❑ 1
I,os owner af the properry,wilf do rhe work and the �
shuduro ie no��ntended or offered for aqle(Section ► '
7044,Businas and Rofessions Code). , � � ;
CANSTRUCTION LENDING AGENCY � - ' '
�
I hereby affi.m tha��here�s o consnue��on lend�ng ogency f« � .. � � � . 1
the performante of the work for wbichlhis permit is issued . - ,
(Sec.3097,Civ.C.). - . �
lender's Name ' � �
Lender's ASldress �
. I cerrify that I Fwve reod this applicar�on and stata�ha�the ► ' � �1
above irrfamation is canect.I agree�o tomply wi�h all County . . .
ordinancas and Staie lows regulat�n9 Plumbing,and hercby ,
authorize represenbtives of this CouMy to enter upon the - � � -
a6o men��oned prope y for inspec�io�purposes. .
� � � SEE REVERSE FOR EXPLANATORY LANGIt�GE ti ,;
i n
Signatu�e of Fmmiftee te . a.
f .. . - . . _ . _. .. , . . . .T
NO Z � N C O � � O Z
j . mN ' { -� � � � � _ �
� � . - o D O � GZl r�. ? Z r'4 � D
� . , A.- r 7o G1 C Oo �
- 2 �
I : . t O p C D m O 0
. m m � A D
, � o N A � �
� - • _�,
�
F .� �, � � � � N O
. '_ � y
� m
- i 1
� . � � ? h
i � � Z
I m N
- N . �
f . • � �
► -
. �
�F i a
. � � . . � � � m
.4•
I
I
�
�
I
�
I '
1
I
�
I
I Z
N
f �
� �
� O
A
N
� Z
' �
�
N
I
{ .
i
' ' � W — .7.O � F F � �-n v w v'n 'q �0 � m r;
' � o o � F� q o T�_aIp'o �� w° o n � o c.'-0 N m S
" � S�' . 7 y O M !1 y � �. N � � � � C 'tD.. .
• � � ^ �..x �p.,0 0 �o-Il �n �^0 tr,A O� � N� ~ N ��
i I S C � n 7' O M N
- . . N a�. 3 �3 � $c �"o'c o 4� ° m' o 0 0
$ 3 ' °-? ' ° '" o ao° ° $ 2• a e�'���qv° �� 'af � O
�p ; p "•O 1�u�i i:o . �.`C<O � r� y K � . t
, ' 's � b3 � "ov ' ° > > F .. _o • on '^ , � � 03 z
�w o E � roa a3' m —^ o Z
� � �` ¢. � �o ' � 3pqw ° � �o�oA ° �� m � c ' �To A
! . � R A A p 0-�±O 0 j O' "O^ U ii � 7�� m � C 0 o CJ _ � -
o -- � ° qF• aa� � a� s �c' a,oHoQa� m ; Noo C
_ � - n T?c T" �, �o m o, ' '� a Fc �v ; n �3 -o
. . Q 0 � 0 O 7.O O a'O � � 7 �0 w n N S� C O F fD � m
' � c° — °a $ °v° o c 3 o,Tcv o= ,�� � . �
N 1 �
. - � �� S T�� Q �y � n j� S a � �s o Q..c0� p
� . o �o � 3 � o N `°'� a 3-c n� m p 3 ' 1` ° -. f�
I' � ' - � O�� t� j � �a�� ° " 0 n H � j-o, '^ �. n � o �
w o �'� � cL� �o a o ao o�:,� n Nb3 ,� 3 D
� N U M � . C � O N � -1
.'e� 3 m m o� .,��T �n � � 3 � w � � n ° o j t
`�� �,+ 4-��.� � � 4 N O 4 Q 7 �.� PJ Q C O Q
. �� 4 O C' 0 N V�( O S Q�+a� N a` O � � 7
_a`� ; ;r c o �a,o °3 �+ o
� p? 7 O Q�O n O'O O,N o p f W� .
� - y � ] C � ' ❑ �� ' O �� p =S „O
, a�o o �-� ^ 'a c=� � , s�o c, �-Ti„ N