Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1589A (23)
WORKERS'COMPENSATION DECIARATION APPLICATIDN FOR PLUMBING PERMIT 1 hereby off�rm thol I have a ceriificole of cor+seni�o self 20�0076 DPW 6/87 � insure,or aca���fico�e oi Workeri Compe�saiion Insuran�e, 7fiA667A o�o ce«+fied copy�hereof(Sec.3800,Lob.C.1 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS P�ol'�cy No. mpony . Cer�iF� d by furnlah�l. Q/6`✓+� O ��3 iIy% FOR APGLI�ANT TO FI��IN(PR!NT OR TVPE� auitcu.� _ Certitied copy is filed wilh Ihe cou y building inspec- ADDRE55 � Q iion dQpo��ment. � ,/ NUMBE4 FI%TURE OR ITEM � F'eE � Da�e���(y` � LOCAUTV 'L. a�+• � V JApplicont C � WATER�LOSET NFARE57 CERTIFICATE OF EXEM7TION FROM ORKERS' BATH TUB ato55 ST. p_nJ S Y!^��f� COMPENSATION INSURANCE SHOwER OwNER La ,Q r L �J (T�h�Mlon n��d naf 6�eomplN�d N fh�work Inwlwd 6y ' Ih�p�rmH Is lar on�hvndr�d dollan(SI00)er I���.) IAVATORY �DRESS . l �is,.i v 'E% I ceriify tho�in�hs perfo.monce of�he work for which�h�s /� /� �+ o ^7_ pprmil is ifsued,I sholl nol employ ony penon in any monner SINK ��TY /,/r[% /�l�iC.. �E�'�' � 'p�/ tio oe�o bxon+e wbjx+�o+he wwken'Compento�iOn lows. D�SHWASNER CONTRACTOR • � ��.�� L' Da�e Appliconl� CLOTNESwASHER AWREss NOTICE TO APPLICANT: li, af�er mokinq rhis Csrrifica�e of Sw!Mn��NG POOL RFCEPTOR D^2 �r«^� E■smp�lon, you cl+o�ld become eubjxt �o +he Warke.i � Compe�eo+�o�rynviaiqny 4f the IpM�Corls,you must forth- :AWN,•iPR�NK:iR5Y5'E�V, Clrv ���'C 4�vc, TE�.�.s�l-9as" wifh comply wirh wch provisioni or �h�f permil sholl be STo.TE l�C. deemed revoked. wqiEp NEnteR utENSE Np. � (j CV,55 � '36 LICENSED COMTRACTORS DECLARATION D�STR�R NO. SSED Bv I hero6y vffirm thot I am licensed undx provisions ot Chap�er 9 �+AS SvSTEM WTLETS O . (commencing wiih Sec�ion 7000)o(Diuision 3 of rhe Bus�neac OUTlE730vER ond Rofessions Cale,and my Ilcense is in full for�s and effxt. 5 PER Sv57EM F�NA� � i DATE �� �AIIDATION a license Number �� LIc.Clasa � � ' U �i FINAL � Conhoc�orr�C 1Q ` Date BY O . ❑ I am exemp���de�Sx. -3��� U : w B.BP.C.For�his reason plan check fee , N � Da�e� Z PLUMBING PERMIT ISSUING FEE S tJ � Siqnature TOTA�FEE � � Plon check opplican� SINGLE FA.MIIY HOME OWNER�BUILDER DECLARATION Name �� ��'��i1 I hereby oHirm�!�at I am exr.mpi irom ihe Contractcr's ticense Add•ess �. . Law for the lol�owing reason(Section 7031.5,Business and � � � •' �ofess�oM Code): Ciry Tel.No. � � � � G j� ❑ I,m owner of�he proparty,will do the wak and�he � 6h�tlurc is nof'mended ar oHarad fcr wle�Seclion ► s.� r� � ��j,.• . 7W�,Businms a�Profassions Code). ���' � Y�" . CONSTRUCT!ON LENDING AGENCY I hereby�firm that�here is a cens�ruction lending agenty for rhe performance of ihe wor4 for which�his permii is issued (Sec.3097,Civ.C.). lender's Ncme Lender's Address I cenily Ihol I heve reod th�s opp�icotion ond s�o�e�tio1 Ihe , above informaiicn is ccrracl.I og�x la comply wi•h a!I County ord�nances and S�a1e lows requloring Plumbing,end hereby au+hori e rep s +et�ves of this Counry�o enier upen the obo� ent� a properly icrirspeciion purpcses. `� SEE REVERSE FOR EXPLANATORY LANGUAGE "v�f/ l� S �igno i ermil•ee Da�e r �� ''+ '�> `i\� y. . f!^.� ` .�\ �.\r,,r•�� ,,''G`,�C `� �r) ..�' \ .n' ..i 1 �r, ��-,I �. i:. 7�, 3', ` �l �h • � � '•��'' 1 � ,J `}� � �\ � \ �� \ \' �� .' .�;� `� � �` �� ' � ;:, � �\ `. . . - \ _,_,-- : • ` '�� .���!' ,,, 4�n 1\ 1� � ' ,� '` - \ � f\\ (� 1 ` , ` � i � 1 �. u` ` �, ; � i . l `� �' t � . \�; � N i U � -� . � R� i � 4 . \ \ \ ' \ 1 \ � �,'\ `�, \ � v: . 1 1 \ \ � ' ` ' �r \ � �,, �, 'N . . ` , �. � �- � �, � ? ; `��, � � � � \ i�\ ` � . \ � � \ � � ` � \ � \ ` .-\ i \ � \ \ \ � \ � ' � ` ` - G� ^ \ � ��` � ` '(•�r•. y N� :^G �f C � `. Z • \ . •. �r` WC��' y ~-+ �.�:N J.^`.•G; ...�. •1 = (: ryY . ! �V� _ C J . . . : o � c� ��•= n �,�.. '_� �_�p T,.. -. `� a?p V N �'. ���� O �•�' ti..ci , -�n r. '�'a i� . O' �� �) 7'� C..^`i�ii "tI�p C '."'�G r�'•J N C 1:1; C+`• �l (!� O. n�.�.n .j`L.G C <i n �", 4 G f, �.,n��:: � f.. ;Y'„ j�'. r; Q' � .n l`- � I. ' V� �w f: -.. ...C . _ i�l v C.� '.) ti A G.�� :3 C .N �in�f � . 4 .. �"nS) 4 J�.'.�C ,r^ ' �. j .: � \ , r ' ',`•' ^ 1 ~� ,' V p� �•,, • ' •♦ O % 0 (S.. O n '1 f Y 3'' r n � �-�. i' (� t7 �, Y. t: �� �� t. q �; L'.. �? `}: C ` .� a � n G '1 C N :� (:r � �! N �.�. } C n � f. ' ^� , v Zl, Z:� t. `.`c' c� ,��- '' � ' X �..,=n . '::, '? •,�..1 .' _ 7 <`-t c..� c � '�^ c..�_ � ��` � o c,��' � " _''`,• ' .. �: G tr � ^ C.'�% p '� ' = � _. '� ��. �' _, ... N "y.' c is . l; C: �M w () ^ ` � ' :.l ,� . N �H r �ti �'�C: � :1 tl C � �� ^ C.,,•�i O .� �N � . � � \ rC) . [•, � +.` ) C N C: y. N O` O �� �' V; �. y- � ..�:/` � � �`! (; C-O �•�..r.. �^i. •:; V r . � t p \ 7 • ,�„ �^ C _' 7 J .N�.. �'^�, C, '� ��J' 'T - '•n `�/'t . \ '\ ' \ � C K 4`_ ^ r1 : , ^. �: (.ts Y, r ' ..(\ :j. Z) �� �) 7 n!,. Ct t:' :; ' �,Y�.�'` ' �\ \ �� '�: �'. •G O � C. �:, -�• ^VC •,j il �,C f�-'r. ���'.1 }\ . C�"' (^ ` n < � �✓ , f. `_�.._3•�. v <..u C �},W � � Y l�• � � .. C �.� � �O' :i 'i.,� � O "p r, � '' i; ...C V n . '� \ `• y .i � � - '' --.y - y . f: L:-� cr�.. M O'C� C C'�-'� �[� ' � , [1 '.j - ^_~ 9' -• ., f•• � - � •C..,'•(- (=C�'�(: , ` \ _ '� ' • 1