Loading...
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 � //' . , ' _ . .. _ � �,.�� , '� ' . . . � .. � . � . .. � � , � � / . .. . _ - . .'„'�. ✓�'