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HomeMy WebLinkAbout1154A WORKERS'CO!.1PENSATIONUECLARATION ]6AO�TA ' hereby affirm that I have a'certiCcate �f�o,�e„< <o��� �E.�.,=-.o, APPLICATION FOR PLUNiB.ING PERtv11T � isure,or a tertificate of Workers'Compensation Insurance,or . . certified copy thereof(Sec.3800.Lab.C.) � , COUNTY OF LOS ANGELES BUILDING AND SAFETY 'olicy No. Company � . - �CertiPed py is hereby turnl e FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILOING ` �/J � � A��RESS �-� 9 S CQ.�Ls.t� Certi ed opy is filed with o ty �1 i i sp tion NUMBER FIXTURE OR ITEM � FEE '� a . WATER CLOSET LOCALiTY Date Applicant NEAREST BATH TVB CRO55 ST. � CERTI'fCAT60F EXEMPTION PROM WORKERS' - � COS�IPGNSATION iNSIIRANCE SHOWER OWNER � I.AVATORY MAIL . . (This section need not be completed if the work involved noortEss } by the permit is for one hund�ed dollsrs (5100)or IessJ siNK a CITY TEL.NO. �g�y � I certity that in the performance ot ihe work for which ihis DISHWASHER V permit is issued,I Shall not employ any person in any manner CONTRACTOR so as to become subject to ihe K'orkers'Compens�tion Laws. CLOTHES WASHER � � � ADDRESS O Da[e Applicant SWIMMING POOL RECEPTOR � � U . NOTIC&TO APPLICANT:If,after making this Certificate ot CITY TEL.NO ��Q W ' Exemption, you should 6ecome subject to the Wnrkers' LAWN SPRINK�ER SVSTEM �' STATE IIC. Ul � Compensntion provisions of the Labnr Code,you must forth• LICENSE NO. I CLASS ��j li '�- with comply with such provisions or this permit shall be WATER HEATER — deemed revoked. � - � GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY � LICENSED CONTRACTORS DECLARA710N O 1����.o-C� � OUTLETS OVER � I hereby aifirm Ihat 1 am licensed undet provisions ot Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 ot the Busi- FINAL VALIDATION :ness and Professions Code,end my Ilcense Is in full force and OATE ��+—&� � etCect. . . . �.�^ Z FIN - License Number�7L Cic.Class J BY � - ���erfa��r TALL[R° ' nate ' N O�O..O� �/(W.,Q �— -�—��—� 2Q�AST GR.hND A F��t�� Plan check fee 1Rqi-fJ�e AS g- ensing rrquiroment as I am a ,'+R�-Ciitfh4eFk�c.'t��aP�F�registered Drofessiona� engineer pLUM81NG PERMIT ISSUING FEE E acting in my profeasional capecity (Section 7051,Bus- iness and Rotessions Code). � TOTAL FEE - �O� PAClFIC INSTA CERS, ING. 4 1 i 54 A Lic.or Res.No. Plen oheck epplicent - . 1��TVE U� #. . . . .5 fiOD1E O\VlY�1.IEIrG�j?�(1;�(�j��Q Neme � � Addrets �y.� • • � 2'S� - I here6y affirm lhat I am exempt from the Contractor's i License La�v tor 1he tollowing reasan(Section.7031.5,Busi- City Tel.No. � � � ���������� • • � 2.rJ�c=j ness and I?ofessions Code): � r � � I,�s�wner af the property,am exclusively contracting � � � � �����, �1 2 2 9—81 with licensed conhactors to construct Ihe praject . �� � (Section 7044,8usiness and Pro[essions Code). /'�a� � � CONSTRUCT[ON LENDING AGENCY " ��Av . � � �- - � � � 1 hereby affirm that there is a construction lending agency � for tht performance of the work for which this permit is ' _ Issued(Sec.3097,Civ.C.). Lender's Nsme Lender's Address � � I certify t I have r t i app�ication and State that Ihe - above i ma ion is rr .I ree to comply with all C nty . . ordin c an a la e lating Plumbing and reby SEti REVERSE FOR EXPLANATORY LANGUAGE � authr iz rep s rt ves of tlis County fo en er up i the � � abo��- ntio e r e fo s0ection purpose. - � I Sig� ture of ermitcee Dat � . / - � �, o x G� f � ➢ N C O y�p � -� G�1 F G '� t 9 �7 �2 2 � '1 �= a Z Z. f r O �a� - �" � c`nn � m -� c c � c � q . �� p � '^ _ � `z rN �• X� m o , -'°ov � o� 9 �m � � . ' ar -� � 9 � .' G . C'a . O O . , r , � y� m ,. c• '. � . , � i c ��� . �P, , 1' �' � � � ' � . Z �, �A . e..x• �: i' � .. �21 i . � •i � . G .. N .. . . � R� �. � . h '� O� .� N V • . •��, , , .... � � � . . � i f�� . � ,�� t . .,,.♦ - i . ' ' �, � *ff � . � . .... � ��..:f , ;,eM , � . �� � . � '`� � �a� O sw�' . �1 . .. '. 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