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HomeMy WebLinkAbout0766A (4) , - � `� � - -WORKERS'CpMPENSATtON-pEC1ARAiIQN--- - . p�PPlICATIQN �QR PLUMBiNG PEFtMlT� � "° � � .. �k here6y uffrm.that!haee a certffimta.o#cansentto sel� --76A6b7A� .. . -. - ensuro;ar a ceceiNcate aE:Workers`Campanxstlon 9nsuronte, '-�CE 817(R€Y.t0/81 j � . . - . or a�certifred eopy therqaf�($ec.380EY,knb.f.} - . � � . . . . � . CQUNTY OFLOS ANGELES� BUItD1NG J4NDSAFETY-- r- PQalicy No. . Lompany . . � . . . ..- _ _ . . .. _ .. . . �Certified copy is Irere6y fumished. � - -� � FOR APPIICANT TO FtLL tN(FRINT OR FYRE� ����' � ' . '�Certified ropy�s fited with tha cou�ty buitdl�g�inspec- -� . - - ADOR65 - hondeportment. - NUMBER _FlXTUREORtTEAA - Q FEE � - . r . .... ���� / ,I� LOCAtlTY - � � . Date. �y� (+r+t ���'-^�^'w' J WATERCIOSEi . . .. !� � : aPP�+t .___._ _�____ . V v h�,4RE5T �:t .. . . . � . ._. �CERTtFIG4TE OF EXEMPiiOfY FROM-W6RKER5` ..- - Z^ 8.4TH N9 -- -� �� � CROSS SF. � - ; - � COAAPEM1ISATI6N lNSURANCE� .. . SHOWER . - � . � QWNER - � . . . � (Thts saetioe e�ed eM he eamplatad[f Nre work.lmrolrad by - � � � . H�r pera�it Fs hr aw lwndrod da0ar;(St�}�or.less•i � � .,,'�. LavarExty� - (l'�� aooRess '���{ � . . � _ . 1 certify that-in.ahe psrformance of the work far which this " - � - � � � � � parmit is issued,4 shakE not empfoy any persan in ony-manner � �NK � - (� CI - .� ; TEL�.ry4, . � - sa as to 6ecome sub�ect to the Workers`Compensatfon LQws. � DtSHWaStiett � � . . � � - �� � -� . CONTRACiOR ' �ate �� Q��licaRt - - -- QQRiESWASHER - -. t' TkCE.T6 APPLfCANF:.tE;after makirtg th�s Cactifimte af-��. -..-... . ..: :. �E� __.� _ -.�: _ _..: ` = , `--� - 4 �pticrn._Ycsu..chaukd,t�a€ome sutaEecE--ta the�:�4ilsufc�i =-S�MMM�NG�F�a€cF}+XSR -_- ..: ..- : - - ..'. -:-..--� - - Gamperisatton . _-. - _. . .:_ . -.- . ._ -- provisiorts af ihe inbor-Gode,You mosr forfh- '�itt . ._.� , .; �_ t£t.Ma. .. �witfi�comply with such praviseons�or.this permit sfrall be - �K`NSPR4NKLERSYSTEAM1 . -� --� SFa7E - -- - � �{ tIC. - dee»ted revOked. - . � � : � � - - WATERHEATEft . - � � [�fENSE NE7.�.1 C{/4$$ . . . . � � LFCENSEQ CONTRACT6R5 QECtARATION . � - p��� � p��y B� .. ( t har�r effrrm lF�k I fem licensed uRder pr€fvisior�s Of CEiapter 4 � GAS SKSTEM -�6UTlETS . ... .- .-j�- ..� . . tfR f F (commencing with Sectiort 7pQp}of Divisian 3 of the&tstrtess 6U7tEt50VER �� f �.� wad PrafessRRans Coda.�nti my.licens�i.�rn fult face.and.effect� - 5 PER SYS� _ _ ._- ... �_._ .; - . _ ?� �r�rac vauD1iT18N � _ . (_ . . .. . „�i,! .,.:. . _. .-. - . .__ 6A'fE tTt._�`� '°`�.'-Y'. ... �� .� Q � � License Num6er�����' Lic.Glass�—31�� -. . , � . - . . . . -- HNA��-.----�--- —"'-- _ . - . . � a.'. � �� Corttractat- 6afe��P`��4�� . . . . . . - BY . . . - . F. I e � � - ❑ t am exempt vnder Sec: � � ---. . . . - . . - � � . . - . - � � ur i _ � . ... . . .. . .. . . . . . . �,- :� ._. . . . - -.___... -----_. _... � � . . _ . - B.BD.C.-for t6is reason �� � � � . - � � y P[an check fee Z � . . , . ... - Ootr.. � � �P€UMBING�PERMIT lSSUlNG FfE 5 � f� � - - . . . -� . . �. ..:-.. � �—. ; . . Signoture� . . . - . . F _ rara�.�� �0 1 t�6 A I ` � � . � . � : Plan chetk appficarst.. . . . . . . . � .. . . � �. . � SINGLE fAMILY � - - ... . . _ � � . . � ��• • • • s - HOME OWFJER BU4L6ER DECLARA710N � �. Name �� . � �_- �. - - -- i., 'eby affirm ihat i am exempi 4rom fhe Confracior'glieense ,� , .:�� ,;y, �. ,.. , �::� .. / -- � �ra��.`J� Addrass--� '�`�•�� � ^ ' - __ . tuw�fc�the fvttowir�g teasar�-�{�ecr'rcx+'-703t.5,�osmeu aRd,�� . •--�- � ---. . " ' .' . . . .._ ..__ ..... ,,. _...�;._ ".a •���t�� 3 Professions Code}: � - - Gty - - Tel.No. � � � � �_ ��•-I,-css owner�ef-the property,w41!do-tbe work and the - . � _� . - . . , � _ - - . 0 6.1.l��� � _ struthue is not intended m offered for sole(Settion � � - � - . � � .. - � � ,., � 7044,Business ond Professions Codej. - - . � - . �� - � � � - � , F . . - _CONSIRllQION lEhtOlNG AGENCY � _ . . � � � - . . -- f .� I hereby affirm tfiot there is a mnstruction lending agency for . ... .. ... .. . . ..- . . .-.� . . . . . � the performwr+ce_ef the wwlc-fcr wkicb;rhis peFmFt--is-'ssued-- - . � . .__ - . .- (Sec.�4T.Eiv:C-.). _ � � � � � � - � , . _ - .. . _ -:- -. -. : - . - _ . . . :_- . _ . . . � . . Lender's Name-_.. _ . . . . .. � . . . � . . � � . .-. . � -. . . � . . 3 .. ._.. . - . . . _ . . . . . . . ... . .. - - - - . ...� � Lender i Addreu .. . . . .- . .. ' I cerlify thpf I hove r¢od,this appEimtion and state that the � . . � - - _ � - � � � �� . - � . obove�iniormatiocv ls cwrect.I vgree to cwnpEy with atl Cou�ty." _�.. . . - - - . . � - - . � � - ; . o:dinances.BDdState tawi-regu(at+ng�Ptum6ing,-b�d hereby - � � - - ���� � -, . . - � - autharizs-representutives-af�khis��Lounty to enter�pon the � �� � : -� .-- � - � � � � � a6ave- ntiwaed properry.. iaspectian.porposes. . . . . . . , . . ; SEE REVERSE FE?Q EXPLANkT4RY iANGUAGE : b-t� _ �.- Si �fat• of Perrnittee . I}are - . . - . � . _ � . .. . -:�_: �:_:.._ .:.:_: .�._-:. _-.__. ._-----' m'4 , u T u C �"'}•� . . , � •_ � ^D ../'s. e/ N y� C C s . � . ,. N O a p � O N p S p�,.� � . . .�. . �� �v N d p�'_ � y v p � '.y- . V �-° N ,a<y p1'.` . . �O Ot 7 1 0 �^ N N !0.0 � m p� d 81 � C V . . . �M? O N,n N C�'+ 'L D �d t- �L E+ � � 'n a� y E o m o � c'o o n � � ,o � 3 y , �o �� m ' L ��C"O' V�,Oi; £N,O p Of c� '�'17w� � t G.}N p O N+.+��.. . . . . 7 �°,) ° $ � c.9ogr000�� s-c�un ° € Qy.ma,' 1 u 0 m,.ro a 0 c o " "' w "p . '1 . . .a Z �✓Q 6 N.� �v=_� } ..- � r�.p Q O u s.� ' a,.. d � E _o}amo Eo p•N�� N=. o.a �,;�.., �" � '." �' E � '� � � ,� o m'YcdE m No'�, � m�. ° p�c ° A �p�a-E "' t aQ �-Q o°o���us� �:' '�i � � : . 4 ad Q— � o p... � . � c p."�"d� N �`• y � � . � u .. � ��t � d ��.� �T'9.p � >�+Q'OL > � � � ...... O O °�'� " � L j�M °'o-" � '" ar pa� ��O"o n= w � '� ft m3v ` °'„ °' ° � � o- ° c N� 4ad _ 3 °' CY O � a � .. m E p °� ° � '�- c N Q D °1 0-a . 3�N °, o Q ° m'a p X".., � � � - m � m � ° �n v � t m a�-' '. o 'm N N mv.o E'�'9 0 � n- � 6s �' `,�='N "o °'c 'rvona` ='aE m >� o O .�} � '' �.... o2S O �' L p' . .T � O D 7, v�7^4' � �'� a.��� �. 6i � . 7J., � � "a 2 O.;O L'�.O� d rj � ��n u� �� 01 � O C�`, '� .. 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