HomeMy WebLinkAbout8721AWfirm RS' COMPENSATION DECLARATION AppLICATI N T O\R OLUMB NG PERMITIhereby, affirm that I have a certificate of consent to tel! in. 2705 66?jA 'W A18 sure, or a certificate of Workers' Compenso!ion Insurance, era CE P.17 (REV. B 18E) yUl certified copr thereof (Sec . 3800, to ) P I' N 1-,,n `TGY O' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS o Icy o. Company GAS SYSTErs OUTLETS Certified copy is hereby furnished. OUTLLl5 OVER FCR APPLICANT TO FILL IN (PRINT OR TYPE 1C7f' Certified copy is filed with the coon uilding inspection NUMBER FIXTURE OR ITE'(d1IRdepartment. WATCR CLOSFT (TOIIFT) 11.114 —/—y AppliconL PATH TUBCERTIFICATEOFEXEMPTIONFROMWORKERS' COMPENSATION INSURANCE This section need not be completed If she work involved by the permit is for one hundred dollars ($100) or lost.) S OWFR LAVATCRY I certify that in the performance of 111e work for which this per. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation laws. SINK DISIFWASHER Date Applicant CLOTHES WAS -ER NOTICE TO APPLICANT: If, after making This Certiftco-e of Ex- emplion, you should become subject to the Workers' Compen- SWIMMING POOL RECEPTOR sation provisions of the Labor Code, you must forthwith comp- ly with such provisions or this permit shall be deemed revok- IAWN "o'Nvtco cvcrr l WATER HEATERed. LICENSED CONTRACTORS DECLARATION I hereby affirm IhaI I am licensed under provisions of Chap!er GAS SYSTErs OUTLETS 9 (commencing wish Section 7000) of Division 3 of The Business OUTLLl5 OVER and Professions Code, and my license, is in full force and P.F. 5 PER SYSTEM feet. ..../ License Number 3'2 /% 3 tic. Clossl.t CITY Contract L/(+1 Date STATE I ortS e>:emp1 under Sec. D'ST"Ci NO. B.BP.C. for this reason IQ rO Dorf: Signature SINGLE FAP."LY HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from •he Contractor's License Law for the following reason (Section 7031.5, Business ord Professions Code): I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Busiress and Professions Code). CONSTRUCTION LENDING AGENCY I hereby offirm Thar there is a consrruction lending agency for the performance of the work for which this permit is issued Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply wi!h all County ordinances and State laws regulating Plumbing, and hereby authorir presentatives of t s aunty to enler upon thn obov a Toned p rty I. I cr, o purposes. t of Parmiltae Date- FEE ate PFIOCA ITY NEARESTCP055ST. 1 MAIL aCDRrSS ,JS. / Q CITY TFL. NO CCNTRACTOR ADCRESS L TEL. CITY NO 4 % STATEUCENSr NO. D'ST"Ci NO. IQ rO I DA EL_, y _ 90 ate. O FINAL I BY Plon check fee PLUMBING PERMIT ISSUING FEE S O TOTAL FEE Plan check applicant Name Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE ' 4 TFL. NO TEL. NO 4 % CLCLASS y VALIDATION ate. OU GO UW CLWrAz 8721 TL it° • •'v 2.10'C0 OZ21—£;9 K 0 0 ch z q n a CD Q. 0? CDCD 0 keg§, --0, B fak/®k§ R§®7 p § /¢m2#§$ -- ¥o a20- 7g1%0 5Pb Esa@ CL E g a a I'D c— sA 7&saGE£- 22 gg% a§ZkQ§&% r, 9 `< E7/\87 k ts I2s$\-i §2 \J \koz, A 2cx_= k©z%&gs ®%S t\ Bn-°22F- A17Joff2 g gm i 3-aB-£'- i#\Ai\ 7 g k2kk%%¢ \77§$ E U) 0 q e r. o: 0 z m v m E 0 s;. k 0 z 2§ Q 2 o m k k k k x3 k CD Q. 0? CDCD 0 keg§, --0, B fak/®k§ R§®7 p § /¢m2#§$ -- ¥o a20- 7g1%0 5Pb Esa@ CL E g a a I'Dc— sA 7&saGE£- 22 gg% a§ZkQ§&% r, 9 `< E7/\87 k ts I2s$\-i §2 \J \koz, A 2cx_= k©z%&gs ®%S t\ Bn-°22F- A17Joff2 g gm i 3-aB-£'- i#\Ai\ 7 g k2kk%%¢ \77§$ E U) 0 q e r. o: 0 z m v m E 0 s;. k 0 z