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HomeMy WebLinkAbout0757A (4) ., ���� WORKERS'COMPENSATION DECIARATION �� � ���� � �� ��16o�a,e� APPLICATION FOR PLUMBING PERMIT � I hereby,aftirm thar I have a certificate of tonsem to self in-� �bA�y�A .. . �� . . ... sure,or a cerlificale of Workers'Compensotion Insurance,or a CE e17(REV.Bi96)- . � � � . " -.� � . ��- - � � � � � certified copy thereof(Sec.3800,Lob.C.� COUN7Y OF LOS ANGELES DEPT.OF PUBLIC WORKS �Policy No.� . . Company � , .. . , � .. . . � � - , . . ... . �� Certified copy.is here6y furnished:_.. �.,. � � , . . BUitDING M .\ - �FOR APPIICANT TO Fltt W(PRINT OR TYGE)- qDDRE55 �.� Cerrified copy is filed wilh ihe caunry buildiog Inspection � �l /�1 f'V � � 'U (�fv departmeM.� ' . . - , . NUMBER . FIXTURE OR ItEM @ F� �p�ALITY� ;p � . . � . . � . . '� `J ... . WATER QOSET(TOILET) � � � - . �Dote . ... � . ...� Applicant . " � CROSSST�1�7�� �jt}�' � rp�d 13'���I���P' . - CERTIFICATE OF EXEMPTION FROM WORKERS'�` - BATH 7U8� � . � . � - . � COMPENSATIONINSURANCE� . -, . SHOWER�� - � � OwNER����J�c. �r,rh�r .fI i � . (Thfs wNion�nasd nm be eomplet�d if fhe work tnrolved by � y�qi� � - - -.. . - . � ., ,'. � th�parmft i�for one hundrod dollar�(f100)or IessJ ��Z� ' LaVaTORv � . . -. .� �' p� nDDRE55� � c� ��� � � � - I certify thaf in the performance of the work For wFich this per- . � 9NK � � � � �� - � � � mit is issued,I sholl nof employ ouy penon in any manner so - UTY TEL.�NO. a5 to bacome subject to the Workers'Compensati n lows. DISHWASHER . � � - � -- n /-2/ CONTRACTOR��N��- , �ate�t l�G��`. ..qPPlicdnt'�-�'��e�� . CIOTHES WASHER � � � . . . . . . .. ADDRE55 �.yA NOTICE TO APPtICANT:If;nfter moking ihis CertiFimte bf Ex- SWIMMING POOL RECEPTOR � -� . emption,you should become subject ro the Workefs'Compen- CiTv � � rEl.No. - � wtion p�ovisions of the Lobor Code,you must for�hwi�h comp- _ iqwN SPRiNKtER SYSTEM � � �ly wiih svcb provisions or ihis permit shall be deemed revok- � � SiqiE uC. ed.� � � . WATER HEATER� . � LICENSE NO. ClASS � � . � UCENSED CONTRAC70R5 DECLARATION..� � � �isTRiCr nio. vaoee55eo av � I hereby offirm 7hat I am licensed under provisions o(Chopler � GAS SVSTEM �OUTLETS . � � 9(commencing with Sedion 7000)of Division 3 of rhe 8usiness OUTLETS OVER • � and Professions Code,ond my license is in full force and e6 � 5 PER SYSTEM � � FINAL VALIDATION } feU. . . . . . � . . , . . ' �� DAT � 0 '. License Number � � � Lic.Clats _ , U . . . . . _ .. .. � . . .... .. � . . . : FINAI � . p� � Contmc�or. . .. . . - ..Dote'... � � , 8Y � � O H � 1 am exempt undei Sea � . . . � w � _ a e.BP.c.for�h�s reason plan check fee N ► z , . Date: �� � -���� 'p�UMBING PERMIT ISSl11NG FEE S `!� � �_ � � s�9�aw�e_ TOT,a�Fee p � �0 7 a 7 A . - � SINGLE FAMIIY - Plan check applicam � � .. � . � � .� {�• • • • •JF � � �HOME OWNER-BUILDER DECLARATION � - . . � I here6y affirm ihof I am exempt from the CoMmctor's License Nome. . . . � -� � � � -� � ---. -- -. . - � • •[j(�J p Law for fhe folbwing�reason(Section 7031.5,Business and �. . � � . . � . Professions Code): , � � Address .. . . � � . e�;:�4�,�O�x,, �I,os owner of the properfy,will do the work and�he City . . - � TeL No. �fl a.1 �'8 8 strucfure is not intended or offered forsale(Sedion 7044, , . , Bustness ond Professions Cade). - � - . .., . . CONSiRUCTION LEN�ING AGENCY� - � �- � � � - ' � ���' . ' � -� �� � � �� 1 hereby offirm thol there is a consirutlion lending agency ior �- . � . � the performance of the�viork for which ihis permit is issued � : � - �� � � - - ' � � - - ' - . � � ($ec:3097.Civ.C.). � ' � , �, � �-j�-�� ,�,�-,� _.5s�v<Ntj• : . . _ Lender's Name / '� � . . - . l Q / � . . . ._ __ . . . .. . . Lender'sAddressl�d,�/J oC.tl,1/' �GG� , � . . ' � 1 certify fhot I have read this opplimtion ond sta�e ihat the � .�� � � - � - � � � -� � ` � above information is corred.I agree to tomply wifh oll Coumy � - ,�� . � � ordioonces and Stme laws regu�ating Plumbing,and hereby � ��- � � . - . � . � �� � � � - - � . � � authorize�represen�atives of this Coun�y ro en�er opon the � � � � a6ove-men�tio /d��_opa�ty for inspection purposes. � � � . _. .. . , . �I��� `�"�^"'��' rF—/O —h�' SEE REVERSE POR EXPLANATORY LANGUAGE y Signature of Permittee ,Date � � . c c� o z G C r � N N � 9 '� '� N ;. ` G b = N �U 'd ro �o . ci y %� ,'�n m y� ?1 z G v 7� � yO r < N Z m � ,� t9 O N,N � .i T � , � .� y ' " �T' � . Z' ' %1 �y, ' �'. � � f�P r � p�- O �, G .-� O '^ N 9 L r � - M O � � � � �, m � ' ' . o � �' �� ��v, Z � o � � - � ' � o '. m N � • N � T � N ; ' m Di " , N ,� . .. . Z � ' � ,� � . N � , N , � . � .�� , � � � 4:. WI� L � �o�w�?�m� �. 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