HomeMy WebLinkAbout0810A (4) WORKERS'COMPENSATIONDECLARATION �swetvw
I hereby a�rm �ha� I have a'certificate ot�o�s�t�o5e« <a.,,,=-.o, � APPLICATION FOR�PLUMBING PERMIT -
insure,or a certificate of Workers'CompensaHon Insurence,or . . . . , ` �. '. . ��-
�certi�ed co ihe�eof(Sec.3 0 Lab.CJ �
r@�a-,�'�ir/�/a���'� COUNTYOFLOSANGELES BUILDtNGANDSAFETY •
Policy No. Company �� - � � �� � � � �.� a„�
❑ Ce ' copy is hereby furnfahe . FOH APPLICANT TO FILL IN(PRINT OR TVPE) � BUILD�NCa -
Certified copy is fited with t county buiiding ins ecC n
NUMBER FIXTURE OR ITEM � �E ADDRESS Q�� �
� de arfine . � � � � WATER CLOSET . �� � LOCALITY
. t
Date�-�L Appticant N AREST � .
� BATH TUB � �../ CRO55 ST.
. CERTIFICATE OF EXEMPT[ON FROM WOR ERS' /
, � COMPENSATION INSUftANCE . SHOWER � OWNER ,i�v
MAIL
(This�section need not be camplefed if the work imoWed � �AVATORY� - � � d`� qDDRE55 -l�.awi �+�+c-�J }
by the petmit in fa one hundred do�axs (SI00)or leu.) SINK- �` �
� � /�–� CITY • �� TEL.NO.oT19.,jy)o U _
I cerlity that in the Derformance of the work for wh�ch this DISHWASHER
permit is Issued,1 shell not employ any person in anY menner � CONTRACTOR V�J � �, �
so as to betome subject to the Workers'Compensafion Lawe. � CLOTHES WASMER ADDRE53 O
�Date -' ADP�icant � . . �`3`3`3� � W
� � SWIMMING POOL RECEPTOR
NOTICE TO APPWCANT:If,after meking this CerHflcate of CI7V TEL.NO.���'No/ N �
Exemption, you should become'suAject to the Workers' LAWNSPRINKLERSV57EM � gTATE r LIC. /� '/ Z
CompensaHon provis3ons of the Labor Code,you must forth• � WATER HEATER � LIGENSE NO. `� ,f p CLASS C` �yb �
with comply with such provisions or this perroit shali be
�deemed revoked. � � GAS SVSTEM �ISTRICT NO. ROCESSED 8V
j OUTLETS � � i
LICENSED CONTRACTORS DECLARATION � OUTLETS OVER __
1 hereby affirm tNat!am iicensed unJer provisions of Chapler / 6 PER SVSTEM / f/`-;� . . ,
9(rnmmencing with Section 7000)of Division 3 of the Busi• � � �-� � �� � FINAL ALIDATION �
ness and Professions Code,and my license Is in full torce and DATE �(J—�,�'�
effect. - � , / _ . � .._ . �
License Number�l���Lic.Class � �" 'p FINAL �
�- /�,, - �'�e�`�� BY ��C
Contracior�[��E�4,�,1�/Dete_� _
� I am exem0�from the l�ensing requitements as I am a Plan check fee � . -
licensed architect or a regiatered professional engineer pLUMBING PERMIT ISSUING FEE S ,� � .
actiaC�n my Droteacional capacity(Section 7051.Bus• � .
iness and ProfessJons Code). . TOTAL FEE �
�
Lic.or Reg.No. Date Plen check applicant =O 8��O A
Neme � . - N. • . .`�,' .
HOMF.OWNER•BUILDER DECLARATION � � � '�
I hereby affvm that I am exempt from the Contractor's Addreas � �,''��7,J��
License Law for the following reason(Section.7031.5,Busi- City � - � � Tel.No. � � • • �a 7�,'�v�
ness and Professions Code): �
� I,as owner of the properly,am e:clusivety cmtrecting � - � , O�D,O Q-�� �
with licenscd contractors to construcl the project _ . �
(Sedion 7044,Businss and Profasions Code). . - .
CONSTRUCTION LENpING AGENCY ' . .
I hereby atCrm that there is a consWction�ending agenoy
tor the performance of the work for which this permit is . � . . �
issued(Sec.3097,Civ.C.). � �
Lender's Name
Lender's Addrcss -
1 eertify that I have read this appllcation and state that Ihe �
above information is correcl.I ag+ee to compiy with atl County SEE REVERSE FOR EXPLANATORV LANGUAGE �
ordinances and State laws regulating Ylumbing, and hereby - .
authorize representatives of this County to enter upon the _
above-mentioned pro rty tor inspection purposes. �- � �
7��r•��w �� -d�/
� Signature of Permittee Dete � �
G
. � G� �\O y . , .
�. � �G �"{�N\qN"^r.\C S� v
a G` Z
2 G p-t a' TY m\� 'O f O
� a Z\Z t'
, "' t�.G f• �,��� G� m� '�' C' ? 6 q
��; . � g � � - �, � N
� � , zo
' , . .. . , ' 1 .%p .' ,O`. G� ym � .. � '^1
" .' . . .^f .�.. T N 'F
__ � � ° ra `o `��y, � � �. \y
, , T �°' , ,o�„�
`. . p �---•
� �. { � . ?� Z�
. . �
's_, � '. � . �.
, - N . � ' ' ,1 .`f S `� � .
�•�
O G
v, �' m
a �,
. N �. . . � . . "
� . .. - . �� � �
. , `�� ' "� t . _t' . . . '. ,
. �. '. '.i, � � �
, . ,, � ' • `y U' ,
` �
' � , ��� � � . - C1
� , w 'i �� �
' � N
� �� �
` -, , N
� � , ,
, '
/
.. . � ; � �4 ��',� �
' ,. � � .. ..x�o'c ° c�;,n�C -'� .
� � .. ..N S . io�.a M A�O R�' ,G fl du ��.''S,�'.Sy .
. " ' . � n b O A � :^���� � G d ='O �...d G�' !"
. - . . �. - � a' �' O ;'' �d:. . ^ ^' N �p�
. . , . . '. L„"� �.. � �° '+ _t c���" �.-..�+ 0.°�`^^„ '`�.o P O � •- �
� � : � �p'C'6 3 O �'v� o G 'w^ pt„o V1 O '.".. �p p" N�.N -. �
W U �io�4 O�..�~'m�CA✓'O �^� �Q~� -"C Q A.� � .� ..
C� ' �k' � o �-� -• o t ��a c o a N�c o�a;�^,����� •t'�y
� .o
O t"n C1 � �.Q n,'o A.io�� '°q,�,:�"w'� w�+"�, 'o� ` ^� � �.o�'+� �
, . . .. . � , .� � �... OO�Ob � ..�tnC, .,. 0 „ n � � _.
� . � . � � o .-� ....o p ..,� - c 7�o c in� t�� o'�i c-1D-., � �,Ci
. G . 'O . � �' �^U-�"o�.�.c..p,�y... � N y N .Z,.�
. - � � � .'�A r�Q N�. �.o' �.v�--�a ot��� Y'o O� .
'� ' . , . .., - . ' ' G+ 3 ec `�O�O. ^'.P•ic—O... ��o�s. � D �
. . v' f� �h'�` D''O �:O N,•. � o p . � ��L
. . - •y . . �^ . o'.' R' 1 ... " o" '� ..
.. . .. ., , .. , ,� �� ..O L'.,�.G n.0 p ie �.-..:C o ue ,.,O F,q'q ���n' .�
. , . _ . . v+ -c'�, . C. -�.- � � Q.'c! ...b 'n n p�,�" n� ,2. -
' � . .. � .. � � ,� .. . _ � ' � p. n . tr,,:0„6 �.v� r ''_ ''�o a«-,.�j1 •:a G °
. ' .. � . . . " ' �'� - - TS' .n4"'"' G"� C^a Y� ".� v O -�N '
p-
' ' °'t:.� ��o� o�o o�.�n�n��oN.� oo°'r. .
' , � c. ..-���': o �'��" o'�^ w� -..,Q� t ..-n ..
. . . "' . . _ . . ' .o " - .ao�• � �" oac XM�c ����i�o'�
. . . � � ' � - � �� ��4� CH O �� •yq ~ ��
, . . � � . . ��q:=ro �O �.'."� ip 7'�. ..•O��O i
" . . . � n V 4�q..' .� v' O ...`f.
� '. , . _ . ' � . � -.O� p.. io Q�O .'G
. . . � - . .. . .. ,,. ��„¢O i`v w � //'
. , ' _ . .. _ � �,.��
, '� ' . . . � ..
� . � . .. � � , � � /
. .. . _ - . .'„'�.
✓�'