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HomeMy WebLinkAbout1203A (6) WORRERS'COMPENSATION QECLARATION . . �R��,��rMTIQi'i fOR �LU/Y�BI��7 ��ii�Y/IT � `� � � 1 hereby offirm that 1 hoJe a certifimte.of consent to self j6A6yp . � .. . � - insure,or a certifimte of Workers'Compensatian.Irrsurartce, Gf 817(REY.10l81) � - � . . or a certified copy thereoE(Sec.3806 lob.C.) /�(� CpU[�jy QF!QS ANGEtES BUIIDING AND SAFETY - P�o�I�ity No. . -. Company�t r'C�:L]___ �- ��. � . .: � � , - .� . . . .. - � ��� . CartFfied copy is hereby furnished. ��.,t - � FQR APPLIUNT TQ F1LLlN(PRINT OR NPE) . BUIt6tNG 1/_ /_�4 � �/j� Cectl4ied copq is fited with the munfy building€rupec- � . A��RES� E T7 <-f . � P- tion department. . FtUMBER FiXTURE OR ITEM p F€E v� l kOCAtfTY--- � � . � � 6ale- � �� --Appkicant ��L/+ :Z� WATERCLQSET.. . � � 7� ~ NEAREST ��s 1 � - . �CERF�FICAtE QF EXEMPTiOPE FROM WORKERS' - �..� Bki�+TUe . � - � . . '�, �. . ca�SS ST. ,- A [L - I - .. .- CQMPENSATION�tNSURANCE . . � . � � � .. {Thls seefioa need-uof.be corapisted.`rf t6e sieorlc iarnhrad by . . �� : SNOwEtr � OWt�R s � tbe pwmit is fCv fMfe Fl�ndrsd dollatt jSl@8}Of Iess.}.. '�r LAVATORY � � � � �! ADDI�55 - Q� �.+�. � � f tertify tfiat fn the performarrce af the work for whicfi this .- �- . -- . w � . - � - _ . . permif is iss�ed,1 sEwl[nat employ any paison in ony manner SiNK � .r . CtTY- V .SEt.NO.- � . � � so os to become subject to Ihe Workeri Compensation.Laws_ � � p�{N/ASFfFR � � - � COMRAtFOR � � �. -DateZ.,���,�ApplicanF ,`n�'� - � � .�-. _ CtOFHES WASHER - �.r � - . . . � F"'�CE-TO APRLlCANi: Ef, qf(er makmg�._tFns Cerrificote,of � ��5� -��' - ;:S�At�MMtN,S'.PL30f.REGeFFpR .._ _ . ___ ._ _._ . . ption, you shauld laecome su6ject,{o ihe�.;Xtwkers - Ct7v�� -- � �- -��� fEt.NO. ��� _ . , . ,'-. .:� . ..`.; . ' . . ..;�:.._ .. - ornpensotion provisiorts o#tfie tobor Code,you must#orth- �(qyyN SPRIFVKLER SYST€M . � wifh camply wiFh such provisiQns or this permit sfiott be . . - SFATE _ j�'1 uC � - deemed revoked. � .. ' � WATfR HEATHt -� . .�r LI�NSE N6. �J- CtAS$ : LtCEN5EQ CONTRACTORS OfCtARATION _ Dtsia . vaocEss�er �- Itt�e4y-aHi€m:zhatlamlicensedunder.provisiansef.Chopter9 �ASSYStEeA .. ottnEls- ""'- . � -. j1-. � . . - . . (commencing with Secfion 7FqOj o#Division 3 of fhe Busirtess . OUTtETSOYER . � �R/ . .�.. }. � . and Profess�ar+s Code:and my ties�is in#uLF�farce attd sHecL .. 5 RER SYSTEht .... . . FINAL ... . .. �. �''��Q�� f'' _ _ VA DATIWd _ � e L�cense Plvmber��J_G3L�L_Lic.Class v,•���. � � �- .-. .. -6ATE..,_t�"r, ,.-::- . . ,,... . � � . _ t ,` �� . . _ _ - - . _ . €INRt c, _ -_ �_ . � �c . Contractor E��a 7� Dote � _ � . . . BY �^"�' . . . . . � Q 4 am exempt under Sec � � - . . . � . � -. � - . . �- � . � . . . - - . . . .. N � -B.&P C-forkhis reason � - . . � - . � � �- Plan cfieck fee � �.- . - .6ate: - - _. . -.. - � �-----P€UM61NG PERMIT I5SUING fEE S � . . - Sigt�afure� . _ - � � � _. . . .. .. , ��j'�Q,u� { . . . . - . .-- . � � . .TOTAL FEf ,�.. Q - .. .. � � - _ . . � - ` . . . . _ . - . � - �es�ory�.. . . f � - . . . .. . _ � Plan chetk applimnt . �-� -: . �� - . � .- � � . . . "� - StNGIE FAMICY � .. . . . . � . � . . - - HQME�OWM1F€R-BUflDER U€CLARRTION � . � Name - - - - - .. .. . � . . i��� '7�x S� �.. '� by affirm that 1 am exempt from the�Conhatkte's License �--.-- - " --- .�_ ' �- �- �-- s r r� � -L, Gor ihe#aNawing reasan'(Be5€iat--743t.5.-Busirress and .:�.Address.:a, . .. . -- , . .... . . � ��s�.us�-va _ ..� .-t . �.,�,: ,.....�; .,.._�. ,,...� __ .-4 , .....:.. . _..s:.: _ �._...�>. . �_ _ . . � - Professions Code):._ -._._ �. . - � City ... - Fei:PFo. - � : - �. � �7_�Q—�,,rv, -. 3 ���I,�as owner of the property,�w4ll do the work nnd the � � . � - � . ` � . � - - - . -- � � _ � '. .. �shucNre is rwt�iniended or offered for sale(Seciion ... - . . . � - - . � ...�.. .. - ..-_. . - . . i . ?044,Busineu and Prafessions Codej. - . . . - . . . . . . � . . _ . . .. . . . . CCSF75TRUCTIC3N LENDING AGENCY � � - . . - . . � �. ;�.. . . . . _. . . �� - t here6y offerm thnt there is a construction lerrdirg agenty for - . . - . . �- . � - .- � � . . . � _ .the getformqnc�of the work for which this permit is issued � . � . . � - . � � . . � � .� . . _ - �, �s��.�,e�Y.c.�: � Lender's Name � � . . � ,. . . . ��- � � � . . . � �ender's Address�,-..�.. . . � . . � . . . . � . . _ . . . . ��_. .. . : : 1 cerfiify tfiat t have read this opplscation and stafe thot ihe . � � � _ _. - � s• above informption is corrett F ogree lo eomply wiFh aI1�CouAFy � � - - � - �. ` � - ordinantes:and-:SfQte lows re9ulatEng Plumbu�g,and�hereby . ....' --..." .-`-: .`..-- ----`.." . . . .. -.-... .. � .. authocize�represenMtives of�-.this Eoumy ro ertter upon the '� -�-: --� -- --� � - - � .; .. abov . e tioned proQ for ingpection purpases.- ��.- � ,.. �. �.. . .p . � .-�� � ..�. �-. ��. � �� � � � � .. -, _ , ... . _.- _.� .i: __ ��-_i SEE REYERSE FOR EXPIANAT4RY IANGUAGE - I - �''��� _ � ._ . :g ture of�Permittee -� . � -Doie . . . . . . . . . . , _ . . . . ,: .. . � _ .... ..'. .. .. f . . .. . .. .. - � � . . .. `. � .- . - . .� .. .. � . . :. .. . .. . . .- . � . . . . ..-_. .. - 1!i �� ' ,� , .. . . . � �� �m� ... . �a. �y a o�ro V G � S N c ^� D `?;d2N m � o o , d 2 v, 'N O C..,� , `� � O L . 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