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HomeMy WebLinkAbout1224Aro WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT - - - - I hereby affirm that i have a certificate . of consent to self 75g667A insure, or a certificateofWorkers' Compensation Insurance, ,-- CE.8t7.(REV. I0/8I) or a certified copy thereof (Sec, 380D Lob.. C:) Policy No. Company_ COUNTY OF LOS ANGELES BUILDING AND SAFETY n ified copy is hereby furnished. O'// Certified copy is filedwiththe county building inspec- FOR APPLICANT TO FILL IN (PRINT OR TYPE) ButIDIN" ADDRESS tion department. - NUMBER FIXTURE OR ITEM - FEE LOCALITY Date 7 - rAp tTcwiaf .tirLL k -IV WATER CLOSET _ _ ---_ ter NEAREST 1 ., 1L) A CjCERTIFICATEOFEXEMPTION-fROM WORKERS'- - BATH TUB CROSS ST. 7 f f v V1 Yc (z - COMPENSATION INSURANCE SHOWER - - - OWNER tJ E T vThissecttinneedmothecompletediftheworkholved- by the perm t is formai hundred dollars ($M) V, less) LAVATORY ADDRESS I or) L. (. VAlIcertifythat -in the -performance--<rf-the-work-#oe-which this permit_ is issued, I shall not employ any person in any manner SINK- - - CITY - TEL NO. so as to become subject totheWorkers'-Compensation Laws. DISHWASHER CONTRACTOR - pate 2c-iwTmm LFl CE ADDRESSTOAPPLICANTIf, after making this Certificate of ptEon you s roufd t4 rs' SWIMMING POOL RECEPTORbeconr .sgbj-e.4.f _::YiQCk or this youit shall rbCompensationprav'euchcomply LAWN SPRINKLER SYSTEMwithwithsuchprovisionsorthispermitshallberoviisions STATE T deemed revoked: - - - - - :-.. - WATER HEATER - r LICENSE NO. - CLASS - LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY 1 hereby affirm that_ f am licensed under provisions of Chapter 4 GAS SYSTEM OUTLETS commencing with Section'7MD) of Division 3 of the Business OUTLETS OVER and Profewons Code, ondmy.license is infill force-andeffect. 5 PEP, SYSTEM FfNAC -- VALIATION h /_' n-l DAT License Number I ic. close 6 Contractor i Qld/A 4 '_ BYMDate a 1 am exempt under -Soc ... - - u B.BP.C. for this reason Plan check fee 2 Date: PLUMBING PERMIT ISSUING FEE E t r( Signature 21 2 2. L A TOTAL FEE_ LCO 4 Plan check applicant - - SINGLE FAMILY I • 1 Q C) HOME OWNER -BUILDER DECLARATION Name by affirm that t am exempt from the Contractgr's,license ..-,. Adrfrsss :,: - ._ ..,,;._,,,,...__;,.;_ r = iv- . Et_ forthe #oftawjrrg'reasoa (SeciFan-3(f3T.5; Business and' T— - Professions Code): - Cily -- - Tel. No. 0 %. C:9.-"8 v - - D1, as owner of the property, will do the work and the- structure is not intended or offered for safe (Section 7044, Business and Professions Code).- CONSTRUCTION LENDING AGENCY • I hereby affirm that there is a construction lending agency for the performance of the work far which this, permit is issued- Sec: 3097, Civ. C.). Lender's Nome Lender's Address I certify.that I havereadthis application and state that the above informotton is correct:, t agreeto comply with all County - ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the -. above-rrtuned property f nspectian purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sigl at of Permittee - Date W oL m b[ a w` m.Je o m[ c c: o a$- a pgo)a ma 3 m c c a c O 0 O o am o c° n t 0 0 b o E oE O u E '' O QAO 3[0 w o CE, mho W C CL x'au.2CL oEabo o n o`o am'o-04 w m 71U3 G30-6 m> wm 6 a Eb oo3 cN E c> m4o N C ap CD U J w .i mC m$o O q dm Q w ..° p yy O h as 3Eo. IE O 3:;ccpos-c-_'o'uoom'NhN a h y` o o o ° ° u a) € o IES X U a° k-+O c°d.°4 a L o m Nwh ca6 W O m n eJi. F i°i .m. U ,0 3 3 G o' o tin D W NC0 W6 O r I d 1I. n O tL Q oz ii