HomeMy WebLinkAbout0813A (4) WORKERS'COMPENSAT[ONDECLARATION �1�taw
1 hereby ef�-um �he� � he�e a'certificate o<<o��<<o self �e.�,�P-.o, �APPLICATtON FOR PLUMBING PERMIT �
insute,or a ccrti£cate of Workers'Compensation Insurance,or , . . - � � . ' `, , -+ '
a certified copy thereof(Sec.3&00 Lab.C � - � �� '
�e��a.��ftp^!a 3ad� COUNTY OF LOS ANGELES � '� "BUILDING ANDSAFETY-
�Policy No. Company - � � � �'�S� �
❑ Certified copy is hereby furnished. , FOR APPUCANT TO FILL IN IPRINT OR TVPE) - BUILOING�O� r �P ' � ,/��
� ADDRESS J iC"i�C.
Certified copy ia Ried with the county building inspection NUMBER FIXTURE OR ITEM • FEE �
� de art ent � LOCALITY
�� � �. WATER CLOSET �J �
Date ApP��ccut NEAREST
� � , BATH TUB p-� CROSS ST. -
� - CERTIFICATE OF EREMP710N FROM WORKGRS' � �
, - COMPENSAT[ON iNSURANCE �. SHOWER � � OWNER �lG
MAI L
(This sxtion need not be compteted if the work involved LAVATORY qDORE$S�6 � 6}7.
by the permit is trn one hundred dollars (S100)or less.) . .
. . . . SINK � CITV �_ ��'sI TEL.NO�-�9 �JO O
— I certify that in the performance of the work for which this � DISHWASHER � � �� � �
permit is issued,I shall not employ any person in any manne[ CONTRAC70R O �
so as to become subject to the Workers'Compensstion Lews. CLOTHES WASMER .G� �3�_�. � U
ADDRESS
Date � Applicant W
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT:If,after making thfs Certificate of dTV TEL.N09�at/�/ � �
�Exemption, you should become subject to the Workers' LAWNSPRINKLERSVSTEM STATE LIC, �_Z/ z
Compensation provisions o[the Labor Code,you must forth• yyqTER HEATER IICENSE NO. � 9.�p � CLASS 1,��
with comply wtth such provisions or this permit shall be � m'°�
deemed revoked. � . �� � GAS SYSTEM�OUTLETS �ISTRICT NO._ - PROCESSED BV ;
/)
LICENSED CONTRACTORS DECLARATION OUTLE75 OVER � �%1
� I hereby ef£vm that I am licensed under provisions of Chapter � 5 PER SYSTEM ��B
9 (commencing with Section 7000)of Division 3 ot the Bmi- � FINAL r D �,ION .
ness end Wotessione Code,and my license is in full force and OATE �U ly .
effect. y ' -�y � - .
/9f�4 ��•� . . . FINAL '
License Num6er Lic.Class gy
f
Contraato_d�� Date ' � � .
' � I am exempt trom t ticensing requ'vements as t sm a P�an check fee
licensed arehittct or a registered professionsl engineer pLUMBING PERMIT ISSUING FEE S � �
acting fn my professional capatiry(SeMbn 7051,Bus•. -
iness and Professions Code). . TOTAL FEE
Lic.or Reg.No. Date Plan check applicent
HOME OWNER-BUILDER DECLARATION Name � , - �
I here6y affirm that I am exempt trom the Contnctor's Addrms '
License Law for the following reason(Section.7031.5,Busi- City - TeL Nm � � �
`:C���'';{�i
ness and Professions Code): . •
� i,as owner oP the property,am ezdusivety cootading � - �!� • ��•�j
with llcenaed contractors to construct the proJect - �
(Section 7044,Business and Professions Cade). . . . � � �:� • •'j�,S Q �
CONSTRUCT[ON LENDING AGENCY . , ,'J j.S(;? ,
I hereby a[firm that there is a conatruction Iendin;agency � �
for the per(ormence of the work for which this permit is . �
D�c�,06'-23
issued(Sea 3097,Civ.C.). ' � �
LendePs Name
Lender's Address .
1 certify that I have read this appiication and state that the � -
above intormation is correct.1 aQree to comply with atl County . SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumhing, and here6y � �
authorize repreuntatives ot this County to enter upon the
above-mentioned prop for inspection purp es. -
/.G/D/�� R.G/��[.t�l� /��/.�� . . � - .
1'�Signature of Permittee Date
y C
� v S � y O Z
't' a D C � N N c m D
.. ' �p ` Z r � � � � � _ � �
, aN r � � N � m � Z � q O
- . m-� O -1 ,� 7� G� � ca D
' , ro➢ ' 1 � -X1 q � ' �? p �'
I - 7�' � � C �y ' Z �
,1 O T m � � T
t N
� � j . � . (y" � O 1�J ➢� -
, . • �. ��
, %�' 4 '�`�.�
_ x
� ' . � �. - . ` � � f `• m
m 1
� =_- i� ; . , , � �
� � . ., • . - - lr� " I N- .
� ' ' ` • D ^
C
m �
N . �M
. . l
. ' ' . . .. . F; . . .
• �
,i.. 1
. 1
� b
. � - . ` ,� 1,�' ' . �
, ' ' ' ' , �, .� '�.1 N
� �
' I ' p
�� - , . �. � . � N
.1 �, ,
+ . . . , .. , . ..
� . ' �t � �, � ' � �. . . " � -- � ' _
r � . , . . .: •, ; - , . . .
� � . � �� , CC n�l'�p��p 7� �, . ..
. . " .- '. � E'�.y. '."' � O C " ,O 1'.'y n � p �.
.. - �- 4 "'-..tn� <o�.a m C A.� �' K � .
. " � . 'R�C O � n r, O r.�fa v�.. �«�O o �v�.,�e° �`�K '� A o W w "� .
'�.�_. ... �.C... I�C � n K
, ._ � �� �,,, ',�.b,ti Li^ .. �� y Fc+'r��."C '� o�3.C io �° �C•, H p ' � ., � .
� '. _ � - - . �7 y�: .o �.»^' O �c.'^'�.. N ��...,c� �oc-•,3 ..A �0 7 ,p .
N � O � ro � C
. .. ' , � O �� � .� "0 . � 0+'0�° 60 � s°�atA'^'�o�n-... �F•m ^ " �•.bn?;; �,� ..
N . . n, t�o P �' "' N7 � cFio m�" n,.Qo � H � r
. - . � ;� �,=3�'��`D »» h � -' � N,�o ""o�c � � ow d
. _ �.+, � -. m'O 4�." �-a n � .. �-1 a p n ••~-'n �n p�
'i . . � . � ' ' � - ' ^ � l.�'p �pt`-�'o�,oF �ap �'�i�'„ O �"rt+ =� N ~ n,� � �.,`� .'..
.���'. O p ;, � b
� . � . . .. ' ._ _. ' .� � '. �_i1 m .so`'�'�p «,�a Gb`h tn 0.�..d C O,G^'~-�i C O A� C �� ,
. .. . „i . G� ��� O . :-`� "' �o O n :° � � W .-, r
ic cr^ ci.�n �' �v ._ �� r,,� ^ '^ ,
.. ' - - ' �, � ^�.G.ac.o ^�^-". ts= oa�.= - �'a�}'yo �
, '.O t� m `"` �: �., '� � n ''o �,-- p, c .^.`� 3 r�
- - %' • a'-� o ° 'o'O'T�' g �'cs A .�o'io .�"' �cn.� rj
" . � � y���a �.G� `�:'`�.n'p C �� 'o =�`O�^,� Q
,.. - �- � o '-$.'•'�o``.n^p" '�-��� �.h.� r^.N;: oo� '�.
_ . . . . . . - . .. ...a�•^.^: o �� � � 0.:,� 10 =n�= ...�•�' �w . .
����� ' . . . ' , � . - . �_ .. �.o'p �ia . � Ob�' w..., . 0 '^ n� 6�
• .. -' . � .. - . � � , .. .. . ''Cl.� O•p'.ty C� 4. �.4 O eo C'O O`^"`.Q G ,_�,,, .�'..O . _,
� � - . � . . . �p ^__io �. o � o�`l O m ro' �r'� �c eO`,e tn�'
' ' � � . . . . _. . �u.'° Y . ^^ .,��.io T .. � �v� ^, �'y�;''
° O
' . . . . . . � . ' � ' �-w tr A t '� �^.O �_ b.,�^'� �fc
. . � • _ . � - '� � .p.� ;o p' . ..
. - _ • � . . . .. r,� F �p'� G
- .- . . ' . . . � , . . . =��ip '^
� �
. . -. ' . .. . ' � ' . '�^�-
1 f�
. -�
_—__���
�J'