HomeMy WebLinkAbout1480A � i
- WORKERS'COMPENSP.110NDEQARATION APPLICATION FOR PLUMBIN�G PERMIT . y�G2.
I here6y affirm that I have a certificate of conseat to self , �bq�q - �
insure,or o certifimTe of Warkers'Compensatio Imuwnce. Q 817(REV.10/81) . . . . . . � �
or a cer+�'e$}�o��+epaf(Sec.3e00.4ob.e.) � COUNTY OF LOS ANGELES _ BUILOING AND SAFETY �
Ys
Dolicy No. Campony 'T ��. � .
�'Cenifiad copy ia hereby fumished. . . . . + � .
❑ POR APpLKANT TO fIU IN(PRINT OR TYPE) eU�� 7� ��-r�
Certif�ed copy�s flfed wlrh the co+rny buiiding inspec-
��ion de ment. . NUM9ER PrMURE OR ITEM � - FFE ��T, .
DGta ✓� -� APPli,ront . WA7ER CIASEf � ?~ � - j
GERT FICATE OF QXEMPTION M WORKE ' BAD+TUB . `"""""'. �� `S �RaY'� � 4aMY� '
CQMPENSATION 1NSURANCE S��Q OWNkR � (
(Thq r�ctlon nwd no�ba eempl�Ird tf/ho werk�nwWed hy
fha pormi!It for one hvndrqd del(an tS100)er(ets.) WVaiORr �� � .
. I canify�har in ehe performance of�he werk fryr which�hte �� � � - ;
permit is isxred.I aholl nor employ an�r�person in�anp manner � 6INK � Cn1'� - - �8..ND. j � :
io m ro becoma wbjart to the Worken'6ompenaelion laws. ot5HwA5Hee - - tpMpq�Tpp � �, � i
pdfe o�p�icanl . � CtOTHE5WA5MER .�� a . ;
NQTICE TO APPI.ICANT: Ifi, dhe� makir1g rhis�eAlfltafe of �������� �
exemptian, you sho�ld beeome ne6jeer �o �he YVorkers' �y Tg,r.�p,
Cwopenwtion prorisiom ef�ha lobor 4ode,you must forth- �,qWiySPR�N�ctERSy$tEht . f , j.�.�
with compiy with wth provisioM ar thi�p�rmil ihctl be _ _ SfAIE �. . � UC ��[ , �
daemed revoked. � . � . - WnifltNEniER�� , � � �Y 1
UCENSFD CONTRACfORS OEGLARATION P cE55ED BV �
. I fi8re6Y affirm thol 1 am Iicensed w�d.er prwisiom of paprer 9 OAS SrSiEM OUTLE7S � �R - � .
�mmmenc��g wuh Seaion 7000)of pixis�an 3 af the evs��ess oun�rsov� f�Nq� VALIDATtON ,
.and Profatsions Code,and my licenx is in(�II force unQ effM. S PER Br57EM � / O l;
LiceroeNum �� ��O lic.Cloas �T � .. . � RAfE '"/�` . V S
FINnL �� ��O� O 1
com�«,a �v �z oare 3t1 3 eY ti• • , •5 v ;
�. I am exempt um�x Sec . . . . . ' ' • y i
'� • •3Q50 �, i
B.BP.C.for this reuson � � Z
Plan check fee ► • , a�`,�C� +
�e: PLUM8ING PERMIT ISSUING FEE S � � �'� ' � 1
Sigrwture __ . Q�j� Cl—'��l i
70TA1 ffE -'jj ,
- . Plan check applicant . . . . �
SINGLE fAMIIV .. . - {
HOME OWNER$UIWER DECIARATION - Nrnne - � - � � � . . _ �
I hereby affirm that I am exemp�from the Conkec�pr's license p�d�s . . . �
Law for the followiog reason(Seciion 7031.5.Bvsinets o� �
{
Rofessions Code): City Tel.No. � � - � �
❑ I,rn owner of�ha pope.�y,will do rhe wak ard�he . � . ' . . i
sfruMure is�inteMled or offe�ed for spla(Sec�ion - . _ . . . �
7044,Business and Profeasions Cade).
CONSTRUCTION IENDING AGENCV � � - �� � � --
I hereby cffirm that thme is o conshudion lending ageMy fbr
Ihe performance of�he work im wbieh rhis permir is iuued . . � -� � � - ��- �� - � � �
(Set.3099,Civ.C.). , - � '
i
� Lender b Name � �
Le'Kler's Address - . . . . . . ._ . - i
I certi(y iha�I have reod�h�s opplicarion and sro�e�hai�he . .. .. . � ;
abore informa�ion i caract.I agrea ro comply with all Goynry �
ordinances cnd S �aws regulafing Plumbirg,ond hereby � i
aothorixe el0 lives af this Counly b enler pon ihp . . . . . ..- . . .
above-m ti ed roperty for ins �ion purposea . �
SEE REVERSE POR EXPLANATORY LANGUAGE .
i
SiqnaNre o e neo te . . . � . . . - - �
� j
. __ _ ..._._ .. _._ . ... ._
� NC D ~ (n � O � N O Z
� . ^7-�^. � "� � � � v Gl '��'
� � � � ' � �D O � � � -zi 'Z r4 S D
_. , , - �^ v C � � m O p .
� . � . � , .. . . - � � T m r�, - � � D
. , , . . � �, 7v � in .
, Z � � , � � - `��J
N �"
� r^ . - �
� � • � �
A . � m
N . �
Z . . �
d
� n. Z .
� ' �
I / . �
�
� . . . � • ' _ - � '
�� . . �� � . . � .
^
� . .
h
F
� Z
�
�
' �
�
A
� �
: Z
�
ti
m
�
tlr •
I�
�
� , �
� • � ° o R, o � �� 3'� �;�o o a o0 o m c�e ° 'n c �s
� � .fD � Q'0� � 7'�+O N t1 m � Q 4� w + � ? v O �. J 7 0
1 - fD C.'�+ r, 4�„C V� ❑ul �U S q V q '
v �- � „ n� �" o � N � �,
� o , � o�'� $3 a� �c o;o'�n o�o :. m' e o 0 0
' . . . . -�y , m.�.0 -��.. � Wo �`.C'o O�..M S� O w ' � � �
or- o � � o otia a
� 3' c '3oF '"m� ' 9 >; � ••�ca�,,o,�=�.„ 3003 Z
u � 'o --o < 3$i w � � 0'�D � �� n O � + s m
�. _ n o .. o �t'a��� • o7O, o $4v� o � � cn � o° �
r� A � S W � A "� �-m p O
. , , . Q A( p � Q0 � 4� �- `� MbwOgaN � NNop C
�' . :' S�'Q 7`M Q '9 A O �. O � C b c o 3 0
q�a � m Q �'c a °'� z ' � o �"'il� 7� � o£ � m
� �a �-�..y �� � O� p � � O T C� � +� � 1D �
� � a� a�-$< .o o Q D �,v � � o •• � 3 rn
� o �� � , oNQ,� 03,°� ommo3oqDo � n
� � .
s �„�o m.o > > naf o N ° v No.oT�„ 3 �• , 3 D
' � o,00ao � �- � �� _ N
� o � p F m Q°- q a-° o ' o v n 'o`� �
� ° ° � � 3 � � T
� �z' a,� � � ��o ° n � on..°� � '"�om ° °com O
I �s� . ,,, n
� H o-•�° � a2 ° ' ' a> > ;
.. ° 4° o o ° °- �° `^Q�� �, ao 3'� �o
� - q� 7 O � � 4'D ^ O �.� O O F w n .
i �O � A i p .. �j �� p' �S�,p
�� . a O � � ?'< � d ca• � u� � S N Q 1D 7�,fn N