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HomeMy WebLinkAbout9556AWORKERS'COMPENSATION DECLARATION 76 `7 DPW 4:87 APPLICATION FOR PLUMBING PERMIThojhereby, o%fjrnl hot I have a certilico!e of tuns nt t self ' sure, or' iarti(icole of Workers' Com n r nee, r ,?. 7CA567A CE 817 (RFV. B,i&6) flcertifiedropythereof (Sec. .! T COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS CompanyPolicyNo. Companyy Certified copy is hereby fur sh r+ 7 ', BUILD NG, pppLLL Certified copy i5 (il tl Ri Idi cyrrr}pection f04 APPLICANT TO FILL IN iF'R!NT O4 TYPE) ACC'.E55 0 ' 'l' 1 l Ve • NUMBER_ FIXTURE OR ITEM Fr` FEEdepartment. , T ,t LOCALITY WATER CLOSET ITOILc-T) O %,—a w CJ r Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TDB /S CROSS ST.. s, 4 " 1 -41 - COMPENSATION INSURANCE SHOWER O O,.tiER `J v- C. .1 .a cC!F' This section need not be completed if the work involved by AIL al L the permit Is for one hundred dollars ($100) or less.) LAVATORY ADDRESS I certify that in the performance of *he work for which rhes per- is issued, I not in IL S'NK J CITY TEL. NO mit sholI employ any person any morner so as to become subject to the Workers' Co nsation La 1 1DISHWASHERIV CCNTRACIOR 6 Q 1 t Dote-0L Appliconl CLOTHES WASHER i G nCDRF55 +yttw'y6' NOTICE TO APPLICANT: If, offer making this Cerfifica f En- emption, you should become subject to the Workeri Compen• the Labor Code, forthwith SWIY..Y.I\G PLCI RECEPTOR I N CITYY b 1_ _ Y 1 to EL. N0 7 QyLT I Ispoonprovisionsofyoumustcomp. ly with such provisions or this permit shall be deemed revok- LAWN SPRiNKLFR S'r STE,1 TE ^ LK. ed. WATER HEATER % ttIV LICENSE NO. D [LASS L - LICENSED CONTRACTORS DECLARATION DISIR.CT NO. PROCESSED BY 1 hereby offirm that I am licensed under provisions of Chapter i GAS SYSTEM OUTLETS 1,079 (commencing with Section 7000) of Division 3 of the Business CURETS OVER I f and Professions Code, and my license is in full force and ef. 5 PER SYSTEM FINAL VALIDATION fec"C LNumbe,Z6 Lic. Class C C LADS I DATE Conlroctor(/-?uil c 7 DaIe FINALBY 'gG 1 I FII am exempt under Sec. 13 B.BP.C. for this reason Plan check fee ' Dale: PLUMBING PERMIT ISSUING FEE S r I (% Signature. 9TOTALf' J 'r3 C "iSINGLEFEE FAMILY HOME OWNER -BUILDER DECLARATION Plan chock applicant rr • s • o o ,,, I hereby affirm that I am exempt from the Conlracloi s License Name C n 1 6 J U 0Lawforthefollo•+ving reason (Section 7031.5, Business and Professions Code): Address 16 :1 %. J 0 I, os owner of the property, will do the work and the City Tel. No. Q . % - 1% structure isnot intended or offered for sole (Section 7044, O Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby offirm that there is o construction lending agency for the performance of the work for which this permit is issued Sec. 3097, Civ. C.). tender's Name Lender's Address 1 certify that I have read this application and stale that the above information is correct. I agree to comply with oil County ordinances and Slate laws regulating Plumbing, and hereby authorize representatives s s County to enter upon the above me 'onldper for inspection purposes. r J SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Per ..oe / Date W I O U ccOh - U a z2 q 0 CD 0 CD Gt/\\\} 7\/z\i 6, f%amE Q§OG 2\7m k»s$, p z f 7 Gkkq%2227kk 2 kj\ tiff k 77§ mE @ag§ a`Qj CL ek 2\2##- b =1 r aAC) X20/% a g_ _¥ao k@kf\ 0 7r) cz* RSI' o k as@I§§&) 2-§«R/9 e` G§2aEo2fZ:3 C,,b CD ¥ 7%\a{\-'dE z z co: kkd®Qn' E E$a222[ \ Gk(§} kgf(J9 2 f #m9AaEx7@« ®• i r\[ rr th rTl Cl) Gt/\\\} 7\/z\i 6, f%amE Q§OG 2\7m k»s$, p sf%°°- kms© 2" f 7 Gkkq%2227kk 2 kj\ tiff k 77§ 9 c E g mE @ag§ a`Qj CL ek 2\2##- b =1 r aAC) X20/% a g_ _¥ao k@kf\ 0 2-&Go§£t Oa\[ka_ m o G cz* RSI' o k as@I§§&) 2-§«R/9 e` G§2aEo2fZ:3 C,,b CD ¥ 7%\a{\-'dE z z co: kkd®Qn' E E$a222[ \ Gk(§} kgf(J9 2 f #m9AaEx7@« ®•