HomeMy WebLinkAbout0796A WORKERS'COMPENSATION DECLARATION ts�enw
I hereAy.afCrm ihat 1 have e��e<<,��e«of consent to 5e�� �e.,,,=..o, A P P L I C A T I O N FO R P L U M B I N G P E R M I T {� .
insure,or a cerfificate ot Workers'Compensatian lnsurence,or '
a certi�ed eopy thereof(Sec.380u,Lab.CJ � � . L�
�i�i -�o-,�rd'^/03oty ���' COUNTY OF LOS ANGEIES "' -- ^ �- BUILDING ANDSAFETY,�
o�cy o. Company � q �3,sy��
� Certi ed copy is herehy furnished. � FOR AVPLICANT TO FILL IN(PRINT OR TYVE) q BUILDING �Ja y�
ADDRESS Ot / �
Certified copy is fited with the cnunty building ins ctlnn NUMBER FIXTURE OR ITEM � FEE
Date'e ",�'e�r Applicant ��� �. WATERCLOSET / � LOCALI7V�,�� �r�,�
NEARE3T
� BATH TUB� � p[�/ CROSS$T.
CERTIFICATE OF EXEMPTION FROM WORKF.RS'
-� COMPENSATION[NSllRANCE SHOWEq �� � OWNER pl
LAVATORV �J MA�� / f
(This section nced not be cOmpleted if the�work imolved �� P� ADDRESS ��l�p L�����v
by the permit is tm one hundred dollars (5100)or less.) �c. a
. SINK �� CITV �� �G'j� TEL.NOsr�-�/�d O
1 certify fhat in the pertormance of the wotk for which this � pISHWASHER /�/ V
- permit is iasuad,I shall not emD�aY any person in any menner CONTRACTOR �l�j
so as to become subject to the Workerc'Com ensation Lows. �
P � � CLOTHES WASHER �' ADORESS ��'3'�hZ .�� �
Date ppplicent SWIMMING POOL RECEPTOH U
'NOTICF:TO APPLICANT�It,aRer making this Certificate of CI7Y TEI.NO. _�0 f W
ExemD��on, you sh0uld become subje[t to the Workers' LAWN SVRINKLEH SVSTEM STATE �1 LIC, �
N
Compensalion provisions of the Labor Code,ynu must forth- LICENSE NO. �7/✓�� CLASS �`� Z
wilh comply avith such provisions or fhis permit shall be l WATER HEATER �l�l —
deemed revoked. DISTRICT NO. ROCESSE Y
/ GAS SYSTEM 5 OUTLETS �.�/ ,�
LTCENSED CONTRAC'TORS DECLARATION OUTLETS OVEP
I hereby at£uie that I am licensed under provisions of Chapter 5 PER SYSTEM A`d '
9(mmmencing with Section 7000)of Divisbn J of the Ausi• - � FINAL �� VALIDATiON
ness and Professions CoJe,and my license is in full force and DATE lv �-��
effecL r /� �
Licens<Number �u��LiaClass v � FINAL � ,
�� p` av r7N, l—.
Contractor���Date .�/
� 1 am exempt from the hcensing?equirementn aa I am a Plan check fee �
iicensed architect or a teeiatercd profeuional engineer �pLUMBING�ERMIT ISSUING FEE S a �
acting in my professional capecity(Section 7051,Bus- �:(;7 Q,Ei 4J
iness and Protessions Code). TOTAL FEE �J � :
LiC.or Rej{.No. Date Plan chack epplicant � � � �ti 7 7•`r�'C
HOMG OWNER•BUILDER DECLARATION Name - '' ` "7 7•'�<� '
1 hereby affvm that 1 am exempt from the Contraetor's AdOreaa� . � O�C�.�+`Z J
Li[ense Law for the foilowing reason (Sectinn,7031.5,Bu<I- C�ry � - Tel.No. � ,
ness and Protessions Code):
� 1,as owner of the pro0erty,am exclusively contracting - �
with licrnsed contracfors to construct the projett �
(SeCtion 7040,Business and Pro(euions Code).
CONSTRUCTION LENDING AGENCY '
I hereby afCrm that there is a construction lending agency .
for the performance of the work for which Ihis permit ls . � .
issued(Sec.3097,Civ.CJ. . - �
Lender's Name
Lender's Address
�I
, 1 cerlify that t have read Ihis application and state that Ihe
- above informetion is correct.I agroe to comply with all County SEE REVERSE rOR EXPLANATORY LANCUAGE
' ordinantts and State laws regulating Plumbing, and haeby ,
IaWhorize representatives of Ihis County to enter uDon the . �
bave-menlioned property tor inspectian purposes. � � .
CJ
i ,,,,.wrn�;<.• �l-�-d�/
gnaturoof ermittee ' llate .
_
�Z � � c� � _ � � '� �
' �IO D D O
4-i o� v� C O
�� S r .N..� c S C Z L) � �
�,�� , r m �D m z = " v
. ; � �x c� �j � m Z Z � r �
�� . Q �; � "j.. �'; � D O
i vD <
, . .. 7�r' p .x.� m y � y
� . � � ' � � � i C D c � r
. ... , � ,:' . ��,�� � r 7� ��-, � � N .
' � � r. . C'J � �» :4 � �
. r ' '� ' . � —�_. . 7•
Z ' ��L .
�. .r . '� : - !� p
m ' .�. I', �j� .� � -{ .
m
O . _ y� } �,
z 1 -- ' � � � � .
_ O • . � . �). 1�
• ' y , . • .. , •��
- . . ! cn
� '; � , � , . :�� . Z
� C
�
m
; ..
' i � • -
, � ,1 _ _Z
N
V
. R:
C)
-�I
O
i �
N
, Z
, �
, � , N
. . . .. . .� h n,cx �ar `
. . .. � . .. . .b n C p :'.� '.' _ ='� � „b o�04' �? .. ` �� R , �
. . . . .��.0 L ttiG n o �.�c ��� i �. � �j� n��.'o
. � . _ . �� ,,.: �,� y �;� �b � !� ,�; �-��'�Y ro� M c,.�� � ` � � � .O
• • - p O c� eo �o � '' vc ...= h.°eH � 'o�� �� " � �
' �. . - . S. c' ' P" � eo � �:P: " o`e "i O t>- C... � ` i.� ^q = ' .o p �W � .
- � 1-'" N ° - o ' -, ° e . ,�' .
� . _ . � .. • � . w � ~ ��•,o- c O � T�r� tr Y� � �o�.❑ � C � a`O„ 1 �C`•. �t -
�] �. ' � � .. 1'n' � C r`C tn: awti.. � h 1'�7
- 4'2,' a� � 4 v:� ,o��a�:" � =" =b �°3 �,�'
' -+, "' `q2.���C�- r - � � =01� � � oQo „ ^. p
. : , � � m� ati 5 "'=•o n'n'o�o..,_ �Aic�'"w C
, . . ' � _ • " . ` � 0 "> '..,n ,�i.a O ...�N n 3 � "+ n
. . - � � � O � 0�ti�.1 N 7 �� V N h..A C .�i�4 y �..�r r'
. ; . �' c. �'� n c t . F.o = ` o� o y a �.G `� F �.N o� . t7
' ��.c � C C G p � " !� : � f
�o
� :. � C cn �c= � �� ti �c-b -.`�' �:o�'o �,�� c n�,, �� �
. . ... . f�i � �•C,'G.Ci O -• O�'O .:.�r �.C O�^' O � ''+ '^V� � C'1
� . � . . . C o C. �'' ,�'.C <o`o �� � O ,o .
, . . . " . . ' . .C.� N 0 n -. N O ,^„ Q p t"� � � N . ia .. . C7
�h �..� {�.
• � . � , . .. . � . � ' ` $ q N o �.� 'c'� � q n��n ti O '� � 2b 2 �c p >
' - ' ' _ '. _ 4_ . �
. . . . a �n'Ls ti G^ a n ..`"� 0." C-,�.`e � " �
� � � .. . .. � � .. . _ .. . � ...O.i� x.��.,•=C �.O.C, G � �.ak " e�� � C ��.n� � .
. - .. ,. . j �o ` ��.o �'� = o ' � <ec � =' _ ` :`� of'1 p
.. ' , ' �.. , . C i O O� �q �� r fo ^p y '� n�� " ` � � � . �.
' _ . .. � _ � . _ ' - . � ec n � �x.", O X_C '�i p . O ta C� �a ' C ='b O �n . .
. . _ .. . � _. " O C`� ; f' O �' �e � m� ^m�,� C�•p. �e � 4.Y .
�c .. ; n ^ � ^ � O � ►.
' � , . .. ' . . . . . y�Q =ti C p 0 ^� o =.4� n �o� o � ��e �"`^
. 1 . . - . . � � .. _. ' � r M� N M�� G