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HomeMy WebLinkAbout1425A (8) WORKERY�oM�N�,TioNo�w�,T�oN � . . . APPLICATION FOR PLUMBING PERMIT � _ � �1 I heroby affirm thM I hare o certificcte of mroent to self yaqbp�q � . inswe,a o tertifiome of Worken'Compensation Insurance, �gV(REv.�0/Si) � � � , , � or o cenif�ed eoPy�he.eof fs«.se0o,lab.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �olicy No. . CAmW^y � � . � . . . . . . . � I CerNfied cqpy is hereby fumished. BUnDING � � Certified c �A���T TO fLLL M(PRIM OR TYVE) � � �p�� d �� .�.� , i1.�,,- �/ �, opy ia fifed with tha counry building-inspec- ' i fiondeportmenf. � NUNIBER . FIXIUREORITfM - � � �p�,q��TY �% �� I WAhR CIOSET � �e _ APPIiCanf � . . . NFniffST � ' . i � CERTIF�CAiE OF FJ(EMPTION FROM WORKERS' �T�'�T� - ���. , 1 - � CAMPENSATION INSURANCE SHOW.ER 4W�ER � � _ � ' (This�ectlon need not M complN�d tf thowark�mrolwd by . - j th�permit b for on�hvndnd dollan(Sf00)or(�ss.1 � uvArortv q�pp��5. 1 "� i'b '� I eenify�ha1 in the performanea of th9 work fcr which this . . •. . � + permit ia iu�ed.I shall not employ any panon in uny monner SINK �� . pPt r,;,t;� � 1E1�� � C; — i - w os to become subiect�o iha Warkeri ComPemation lpws. uiSr�wnSMR �p� C.�`-K�- � �`{Dura�.�.Appliwn'_ ..-!' 6 uoTHESwnsHEk � nooRESs . .� .; � NOTIC�TO APPLICAM:if, a er moking�� ' �tertificate t � ' Ezempfion, yo� nhwid becoma-s�bjetin ths Workers' � SN7MMINGPOQLRECE➢fa1 Compensafion provisiprp of Ihe taba Goda,yoy must foAh- � . �'�.� � lAWNSPRIFMIERSY57EM � with compiy wilh euch pmvisiwn or this pertnu ahaYl 6e � {TAiE i1C. � deemed rerqked.. � WqTERHFqTQt V���� U^ss ' LICENS�EONTRACf4R$OE�IARATIQrI - 06TRltt NO. ; � P�S�D 8Y J I hmeby affnm thaf 1 am licemed�nder proiiaions qf S,hap�ar 9 , ��M WT� � � 1�y�_ � ; (rommencirg wi�h Sxrian 7C00)of Oirision 3 of tha Brrsineu punErs Wpt . d nnd aofeu�om Gode,m,d my tkerrse ro m fuu force m�d eBx+. s PE�srsr¢nn flNlu VALIDATION � � license Nvmber ��c.Closs - - � . � . �� . . C) , . . . . '.FINAL � O � Connada- � -Dalle � . �.�Y .� . r+ � ; ❑ 1 am exmp�undx Sec.� � .� .... . . . . . . . . �- e.sa.c.fwrh�9.�o� plancheekfies `(/ ��� " . �Q: � PlUMBING PERMIT ISSUING FEE S .�� ��. . 1 Signature� ,. ` . . j TOTAL FEE � � � .. . . . _.... . . . Plan chedc appBcanf . � . � � � SINGIE FAMILY . � HOME OWNER-BUILDER DECLARATION �^�e - � - ' � � � �1 �.2 5 A - � I hmeby effirm rhat I am e:empt 6om rhe Contracror's Lice�ne . � , - � law for tha fo�lowing reoyon(Section 7031.5,Businms and �rh3- � �+• •.• . •5 ; Profess7orK Code�: Gry � Tel.No. . . � � � 1 • •1650 � I,as owner of the propeny,will dv the wo�k and Ihe . � - chucrure is nat intended w offered for sale(Secrion ..... � _ � , _ •..a �1 ��O U. I � 7041,Businena o�Professiom Code). - . , I mwsrnucrrorv�oiroc nc�wcr 0 2 0 7—8 4 ; I hmelry affirm thot�hera is o construcfion le�ing agancy for, � . ; tAe pe�formance of tha work for which�h7s permit is iaeued .- � - ? ISec 3097,Civ.C.). . . � • j Lender i Name ' � I le�e[s A�dress . � ' � . - � I certify thal I hava read this applica�ion a�d stofe thm the . , � above informo�ion is correcl.I agree M compiy with all County . ordirwnces and 51afe laws regola��ng Alumbing,ord heroby � � � auihorize represeMatims of tbis Counfy to anrer upon �he - � �� � � . � � " ' � � '� a6ove-mentioned prope�ry f ' apecr�on purpoaes. $EE REVERSE FOR EXPLANATORY IANGUAGE � �.!� ,� �7� y � � �L `'_-' � L-.zi_„( " � i �'Jigna/oro of / Iae � � Daf�B . _ . . . � . � . . . � '_\ (% . . . , � , __ p C � = D y � � . .. . Z � � � O N ro � N D .- '.. V�G '' � N Z q � z G m A _ --. _ . n,� n "� � p Gl O ' A O � � G _., ' � . o r�" . � C ➢� f�l � N P __. . O . T � A ' _ m D O \ , O ' ~ m ti . C 3 �J N z , � � �- ' � � � � N 7� � ' N Z Z ' '� �� ?. O � -+ m m � N Z � � ' O . � N � � N 1 `�. " � 1. p :� � Y� ' �^ � O �0 �O c N � � . 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