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HomeMy WebLinkAbout1530A (8) r , WORKERS-��PE�,s�N�«ARAf�o,� �� APPLICr�►Ti�RI �Q�R PLUjViBti��PE�iri�i�,���� � � � I hereby offirm that i have o ter�ificote of consent lo ut! 20-D026�PW 6l87 ; � - ;' .^' : � insure,or o cerlificate ot Wo�kars'Compenwtion Insuronce, 76A667A � �`- �'� or a ceriified co�pys th1ereof�$ec.3800,l C. r /� . COUNTY OF LOS ANGELES DEPT.OF.PUBLIC WORKS PQolity No�d����"" "Compony ��'���� � Cerlified copy is hereby furnished. BUILDiNG FOK APPLICANT TO FILL W(P{tINT OR TYPE) ADDRE55 2 i d z3 J�i U✓� Cerlified copy is filed with 1Me mv ry building ins � iond�epsa�r�m,enf. r$1MBER fl%TUREORITEM � fEE ���rcY Do1C�Sl�Appli nt WATERQOSEl NEAREST CERTIfICATE OF E MP 9N FROM WORKERS" � BATM TUB CROSS ST. COMPE N INSURANCE . SHOWER OWNER d�)���? (Thi�wction nr�d not eompbbd.H ffi�wArk inrolrad 6y Mpi� Ih�p�r�wN Fs for oh�lwndred aellari(31DOf or I��a.) �_ LqVqTORY A��RE55 � I cerfify Ihnl in the performonce of ihe wark far which this ��Ty TEt.NO. � psrmil is issued,f sho11 nof employ any parson in any monner SINK so aa lo become subject fo rhe Worker' ompansotion La . � DISNWASHER COMRACTOR (/ [7S `-'Py1 1 DoSe�APPlic QO�NESWASHFR ADDIiE55 �b � NOTICE TO APPIICpNT: ! af r making this er�ificate of � E■amption, you ahoul b ome su6'�ect to the Workers' � SWiMNJNGP00�RKEPiOR ��Ty . '^� TEL N0. ��f� �t COmpensalion provisio the Labor Coda,you muif forth- UWNSPRINKLERSYSTEM i with compty wilh suc provisions or thia permit shall be STAT � �C� UC. 6 de�med revokEd. � ' WA7FR HEATER uCENSE NO. A C1A55 � tICENSED CONTRACTORS QECIARATiQN OISTRiCT NO. ESSED BY � I hereby offirm thpf 1 am liCanaed under provieions of Chapter 9 GAS 5YSSEM OUFlETS ��_ � (commencing with S�ction 7000)of Ofrivon 3 of!he B�ainas - OUTLEf50VER } ' and Profeuions Code,and my license'rs in full force and effect. � 5 PE 5YS1EM FINAI YAl10ATION LL' � oY`,� onre � � License Number lic,Clas� FlNAL � Controctor � �'��� �ate �9 Z' � BY O `s Q ti1 '� 4 om exempt under Sec. a ? t 8.8P.C.for�his reoson p{an cheGk fee oa�a: �t 5 3 Q A � ° PLUM8ING PERMiT ISSUING FEE 5 #� �. • �S ' SigtwWre r �( �� � TOTAL FEE (�� � Plan check applicant . i SINGIE FAMILV `I+t 4 6 5 p ! HOME OWNFR-BUIL6ER DECLARATION �ms y�!��r,Q x i I hercby offirm that l am ezemp�from�he CoNroctor's Litense � " Law for the following reoson(Section 7037.5, Business ond Address ��t ��$9 ` Professians Code): �iry Tel.No. ❑ I,as owner oi the properry,will do ihe work ond�he 4 � 1 str�dure ia not intendad or offered for sale �SeUion i 7044,Business and Professions Codej. I CONSTRUCTION 4ENDING AGENCY � I herehy affirm tbat there ie a mnstruction lending agency for � the performance of the work for which this permit is issued (Sec 3097,Civ.C.). ( Lender's hlame I Lender a Address � 1 cerlify that 1 hove read lhis appl�cafion and state fhol�he � obove informa�ion ia corrett.I agree�o tomply with all County ordinances and Sta�e fows regufoting Vlumbing,ond he�eby ou�honze repre�enlotives of ihis County to eNer upon the � � + a6ov eMiOned p�opBrty for inspeCtion purposes. � r2 SEE REVERSE fOR EXPIANATORY LANGUAGE I Signature of Permi ee Dote �1 � 1 P . � � � 'C. `' ,'. `!v"t, U U ..... `[y � � N Cp ._ ` L fa w C �� Cu ' u�� Y, � »: :'�' .C.' [: . C. C: � � U' G C ..L. � . :. ' C O..0 � D C �: d � � 6 v C O j i i�oy y,t: Q �� M1r:p`„ a v, � � p U a O � " �;•?_ I ,)� �'.' 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