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HomeMy WebLinkAbout9556A (21)WORKERS'COMPENSATION DECLARATION 76 `7 DPW 4:87 APPLICATION FOR PLUMBING PERMIThojhereby, o%fjrnl hot I have a certificate of tuns nt t self ' sure, or+ iarti(icole of Workers' Com n r ncr, r ,?. 7CA567A CE 817 (RFV. B,rsaJ flcertifiedropythereof (Set. .! 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 cytrr}pection f04 APPLICANT TO FILL IN iF'R!NT O4 TYPE) ACC'.E55 0 ' 'l' 1 l ve • NUMBER_ FIXTURE OR ITEM Er` FEEdepartment. , T ,t LOCALITY WATER CLOSET ITOILc-T) O %,—a w CJ r Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TDB /S Cu= 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 dollop ($100) ofless.) LAVATORY ACDRFSS I certify that in the performance of rhe work for which this per- is issued, I not in IL S'NK J CITY TFL. NO mit shall employ any person any moaner so as to become subject to the Workers' Co nsation La 1 1DISHWASHFRIV CCNTRACIOR 6 Q 1 t Dote-0L Appliconl CLOTHES WASHER i G nCCRF55 yttw'y6' NOTICE TO APPLICANT: If, offer making this Cerfifica f En- emplion, 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. NO et%f QL/C T I I O 0 h 7spoonprovisionsofyoumustcomp. ly with such provisions or this permit shall be deemed revok- LAWN SPRiNKLFR S'r STE,1 TE ^ ed. WATER HEATER % ttIV LICENSE NO. ID [LASS L - CIA 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 OUTLETS OVER I f and Professions Code, and my license is in full force and ef. feet. 5 PER SYSTEM s I FINAL VALIDATION DATE Lice Number Z6 Lic. Class 4-34 C Conlroctor(-f7-'/I (i /I L•7'Uale I FINALBY 1 I am exempt under Sec. B.BP.C. for this reason Plan check fee' 100, Signature Dale: PLUMBING PERMIT ISSUING FEE S r I CID f' 9 JJ C "iSINGLETOTALFEE FAMILY HOME OWNER -BUILDER DECLARATION Plan th-1, applicant rr • s • o o I hereby affirm that I am exempt from the Contractors License Name C !' 6 J U lJLawforthefollo•+ving reason (Section 7031.5, Business and Professions Code): Address I : f 1 %. I, os owner of the property, will do the work and the City Tel. No. G . % - 1% structure is not tended or offered for sale (Section 7044, in O Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby offlrm 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 represen!arives s s County to enter upon the above me 'onldper for inspection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Per ..oe / Date W I O U ccOh - U a z2 q 0 CD 0 CD G/\\\} si70 CD @ f% cm 2-a,cp »zir oe® R@m m p z Q f 7 q%2227kk(bnk39DQGkkw tiEf k 77§ a` Z; Trk§+-®®a 6,) pi3_9sGlb .0 r aAQ& Xor alb a g_ _%Aao a m 0 7 7r) o k as@I§§&) 2-§«R/9 23 CL f-'dEZ:3 cbzz c222«-2°°§ z. kkd®RQn' kgf(J9 2 f #C9AQ)EX— A• i r\[ rr th rTl G/\\\} si70 CD @ f% cm 2-a,cp »zir oe® R@m m p Maks$ %°°- kms© 2" Q f 7 q%2227kk(bnk39DQGkkw tiEf k 77§ 9 c E g a` ED Z; Trk§+-®®a 6,) pi3_9sGlb .0 r aAQ& Xor alb a g_ _%Aao a m 0 7 cr.j5M 8cRM 1xg &£ 2-&Go§£t a\[ka_ m o G o k as@I§§&) 2-§«R/9 23 CL f-'dEZ:3 cbzz c222«-2°°§ z. kkd®RQn' kgf(J9 2 f #C9AQ)EX— A•